Internal Information

REQUEST OF ANALYSIS	Date of receipt:	Visa:

☐ TIME CRITICAL SAMPLES (Only for customer for which ones this type of analysis is covered by a quote) Request must be provided 48H prior to shipment, feasibility must be agreed with the lab prior to shipment. Indicate max. time between sampling and analysis: In the event of a mismatch between request and sample labelling, the analysis will be launched without waiting for customer feedback to guarantee compliance with time constraints, as long as security compliance is ensured. The time critical samples analyses are invoiced as express samples with an additional urgent fee.

CUSTOMER INFORMATION

Shipping Address (for the report / certificate)	Billing Address ☐Same as the Shipping Address
Name: Company: Address ZIP: City: State: Country: Telephone: Fax: E-Mail:	Name: Company: Address ZIP: City: State: Country: Telephone: Fax: E-Mail:
Confirmation is sent by email automatically after registration

FINANCIAL

PO number (listed on the invoice)	Offer number

QUALITY STANDARD

Please specify:	If other:

SAMPLE(S) IDENTITY AND DESCRIPTION

Please specify:	Product Name:	Stability sample: if yes specify conditions: °C %rH duration:
Product code:

TRANSPORT CONDITION

Please specify:	If other:	Data logger in package

STORAGE CONDITION

Please specify:	If other:	Remaining sample to return after analysis

HAZARD INFORMATION

Type of risks:	The sample is a GMO (Genetically Modified Organism) The sample is a bacteriophage
MSDS number : (please join a copy if available)	Biological Safety level: If other:
☐	☐	☐	☐	☐	☐	☐	☐
require specific safety measures, same applies for “unknown risk” Other information:

ANALYSIS

☐ Single sample for several analysis, aliquoting has to be performed by SOLVIAS FRANCE SAS. In that case fill a line with the references of the main sample and one additional line per type of analysis including needed quantity
☐ Additional sample for on-going analysis (please specify type of analysis)
Batch number	Standard / Method	Specification / details	Quantity of samples per analysis	Validation / Routine (1)	Timeline(2)
V/R	If already validated, indicate method number
; Nr:
; Nr:
; Nr:
; Nr:
; Nr:
; Nr:
; Nr:
; Nr:
; Nr:
; Nr:
; Nr:

(1) V: Validation R: Routine (2) E: Express S: Standard

COMMENTS

☐ Sending of raw data per scan requested

By my signature below, I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge.

Date:	Name:	Signature of the customer: