Sample Submission Request Form (to accompany each order) client information billing information (please indicate if the same)


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NameSample Submission Request Form (to accompany each order) client information billing information (please indicate if the same)
A typeDocumentation


OMIC USA Inc., 3344 N.W. Industrial Street, Portland, OR 97210 Tel (503) 223-1497 Fax (503) 223-9436

e-mail: sales.us@omicusa.com URL www.omicusa.com


Sample Submission Request Form

(to accompany each order)

CLIENT INFORMATION BILLING INFORMATION (please indicate if the same)


Company:







PO #:




Contact:







Contact:




Address:







Bill to:


































Phone #:







Phone #:




Email Report:







Email Invoice:




(these will be the only addresses included in the sample communication)








































Relinquished By:

Date/Time:
















For Nutrition Labels:










Serving Size:




oz or




grams

Korean Certificate for Export
















Servings per container:




(if yes, additional information will be required.)










Amount of Added Sugar:






















Type of Added Sugar:




RUSH ORDER: 3 days or 5 days (circle one)







Client ID (Lot# - reflected on report)

Matrix (reflected on report)

Analysis Requested

OMIC ID

1














2














3














4














5














6














7














8














Comments:




Report Date:



Price:



Office Use Only:

Received by Signature:




Date/Time




Acceptable/Temperature






















Date Validated By:




Date










Please call if there are questions regarding these requirements or completing the form. FM-003_R2 08/09/2016

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