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Section I :

Company Identification

Company's name:
Department:
Address :
City/Prov. or State : Postal or Zip :
Phone #: Ext:
Fax :

Section II :

Administrator

Name of person in charge (admin):
Email of person in charge :
Phone #: Ext. :

Section III :

Invoicing

Name of person in charge (invoices):
Check if name of person in charge is required on invoice:
Email of person in charge :
Check if invoice needs to be sent by email:
Invoicing email address (if different from person in charge):
Phone #: Ext. :

Section IV :

Invoicing address (if different from section I)

Department:
Address :
City/Prov. or State : Postal or Zip :
Phone #: Ext:
Fax :

Section V :

Names of Laboratory Services' Requesters

Name, First Name

Title

Email

Phone #:

Ext.

Please select services that are expected to be requested

ENVIRONMENTAL Analyses (Industrial Hygiene)
TOXICOLOGICAL Analyses
MICROBIOLOGICAL Analyses
Communal type face mask/ Respirator Filtration (N95 type) / BNQ Attestation for FPP
Others
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