Sample Submission Form

Chain of Custody
Include the following in the package with the samples:

1. A completely filled out Sample Submission Form

2. MSDS(s) for sample(s)
3. Payment information, either credit card or hard copy of purchase order

(Failure to comply with these instructions will result in a delay of sample analysis)
Customer Contact Information
Customer Name:
Company Name:
Address:
City, State, Zip Code:
Phone Number:
Email Address(s) for Results:
Industry:

Ship To

Bill To

Payment Information (Hard Copy of PO or credit card information is required prior to releasing results)
Purchase Order # or Credit Card #:
Contact person for purchase orders or Name on credit card:
Expiration Date:
Security Code:
Type of Card:
Provide E-mail for CC holder or PO contact for Invoicing:
Type of Service
Rush (next sample(s) analyzed)

Surcharge Price
List + 200%

Priority (2 4 working days)

List + 50%

Normal (typically < 7 working days)

List Price

Would you like your samples returned to you?

Yes

No

Shipping Account Number

If no shipping account is provided, you will be charged $50 for non-hazardous samples.
Hazardous materials & controlled substances will be charged $200 if no shipping information
is provided. The shipping fee is waived if we are provided a shipping account number.
**All Hazardous Materials and Controlled Substances must be returned.**

Sample Information and Analysis Conditions

Sample Description or Sample Type (e.g. carbon, kaolin, silica, lactose)

Particle Size samples require refractive index and dispersion info:

Gas Adsorption & Chemisorption require pretreatment conditions:

All samples will be analyzed using our Standard Operating Procedure
(SOP). However, if you provide details of a specific method, such as an
ASTM, ISO, or in-house validated method, we will follow that method. If
you provide a previously analyzed sample number or project number, we
will duplicate that method as well.

Customer Sample
IDs

ANALYSES
DESIRED

(List individually)

(Include test number(s))

This sample
requires
GMP testing

Sample Storage Instructions

Yes

No

Room-Temp

Fridge

Freezer

Yes

No

Room-Temp

Fridge

Freezer

Yes

No

Room-Temp

Fridge

Freezer

Yes

No

Room-Temp

Fridge

Freezer

Yes

No

Room-Temp

Fridge

Freezer

Yes

No

Room-Temp

Fridge

Freezer

Yes

No

Room-Temp

Fridge

Freezer

Sample Classification
Non-hazardous
Hazardous
Controlled substance (I-V)
Non-hazardous
Hazardous
Controlled substance (I-V)
Non-hazardous
Hazardous
Controlled substance (I-V)
Non-hazardous
Hazardous
Controlled substance (I-V)
Non-hazardous
Hazardous
Controlled substance (I-V)
Non-hazardous
Hazardous
Controlled substance (I-V)
Non-hazardous
Hazardous
Controlled substance (I-V)

**Controlled Substances and Hazardous Materials (as defined by DOT and/or MSDS) are subject to 25% surcharge
Results will be sent electronically in PDF format. We may be able to provide Excel files if requested.

Micromeritics Analytical Services

Attn: Lab Coordinator 4356 Communications Dr. Norcross, GA 30093
mas@particletesting.com www.particletesting.com phone 770-662-3630 fax 678-348-7565