Agdia Testing Services Sample Submission Form

Agdia Testing Services Sample Submission Form
Agdia Incorporated
Phone: 1-800-622-4342
52642 County Road 1
Fax: 574-264-2153
Elkhart, Indiana 46514 USA
Email: testing@agdia.com
Please submit samples via overnight courier (Fed Ex, UPS, etc.)
Sample Submitted by:
Submitter's Name:_________________________________________________
Company Name:______________________________Accounts Payable Contact:___________________________
Address:_________________________________________________________
City:__________________State:_______Zip:_________ Country:__________________________
Phone:______________________Fax:_____________________ Email:__________________
Preferred contact information for results (email addresses, fax numbers):_____________________________________
Send invoice to: Check here if same as above [ ]
All results are confidential to submitter. If you would like the invoice to be billed and results sent to a third party, please complete this section.
Company:_____________________________ Attn: ______________________________
Address:_______________________________________________________________________
City:____________________________________ State:_______ Zip:_________ Country:_____________
Phone:_____________________Fax:____________________ Email:_________________
Method of payment:
[ ] Bill to purchase order number:____________________________
[ ] Wire Transfer
[ ] Check Enclosed
[ ] Visa [ ] Mastercard Account Number:________________________ Exp. date:__________ Zip Code: __________
Cardholder’s Name:________________________Cardholder's Signature:_________________________
Mailing Preferences:
An electronic copy of the report (email or fax) will automatically be sent to submitter. If you would like the results to also be sent by mail,
please complete the information below. There is a $20.00 additional charge per mailed report.
[ ] Please mail a hard copy of the final report
[ ] Please mail an extra hard copy of the final report to a third party:
Name:___________________________________________________________
Address:_______________________________________________________________________
City:____________________________________ State:_______ Zip:_________ Country: _____________
Sample identification:
(e.g. Impatiens 'agdia medley' 001) For multiple requests use multiple forms.
Sample Type
Sample ID
1
6
2
7
3
8
4
9
5
10
Sample Type
Sample ID
Test(s) requested*:
________________________________________________________________ *If you are not sure which pathogens to test for, we recommend
one of our screens. These contain tests for frequently encountered viral pathogens of a particular crop. Please feel free to call us to ask which
screen suits your crop best, or check our website: www.agdia.com.