Sample Submission Form

Lebanon Sample Submission Form




GMP
 Non-GMP

Contact Information
*Client
 *Client Phone
*Prepared For
 *Client Email
Additional Emails (please list all people's emails you would like to receive the report - separated by commas ','
Client Address

Specimen Information
*Sample Name
 Sample Description
Product
 SKU
*Lot Number/ID
 *Sample Quantity
*Is this testing for a drug filing?
 If drug filing, please specify
*Is this a controlled substance?
 If controlled substance, specify NDC#
If controlled substance, specify Schedule
*Biosafety or Toxicity concern?
Specify class of Biosafety or Toxicity concern

Containers samples
Material of Construction
 Size of sample

Testing Services and Special Instruction / Requirements / Requests
*Potent Compound present?
If compound present, please specify
*Special Handling
If special handling compound, please specify
* A PDF of the report will be issued upon QA/QC approval of test results. Do you require a hard copy of the report to be physically mailed as well?
Do you require Raw Data to be sent?

Sample Treatment
Curia Standard Occupation Exposure Bands
 Occupation Exposure Bands Suffixes
Refrigerated or Frozen?
Storage Conditions
Special Handling

Additional Information
Additional Information

Sample Disposition

Curia will retain sample(s) in the laboratory for 30 days post report issue date then dispose of sample(s) unless other arrangements are requested.
Dispose of Sample after 30 Days Dispose of Sample after Days (Please enter number of days in "Sample Disposal Days" (Below))
Return Sample Upon Test Completion

If return is requested, please provide the following:
Carrier
Account#

Approval of person submitting samples for testing:
Name:
Title:
Signature/Date:
  
Expected Sample(s) Delivery date to Curia site:

Shipping Details

Please Ship Samples To:
Curia / Whitehouse Laboratories, 291 US 22 East, Salem Industrial Park, Lebanon, NJ 08833
Phone: 908.823.9300
SDS / MSDS required with every submission
       

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