Laboratory Service Order (LSO)

1. ANALYTICAL CONTACT

Contact Name(Required)

Person who will be contacted regarding any technical questions on the analysis and will receive the results.

Mr./Ms./Dr.Mr.Ms.Dr.Prof. Prefix First Last

Contact Email(Required)

Phone(Required)

Email cc(s)

Separate multiple emails with a comma.

Final reports are issued electronically.

2. COMPANY INFORMATION

Company Name(Required)

Customer Number

Your customer number is an X-digit number that can be found ... or here.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe

3. ACCOUNTS PAYABLE CONTACT

A/P Contact Name(Required)

Person who can answer questions regarding payment and will receive the invoice.

First Last

Email to Receive Invoices(Required)

All invoices are sent by email.

Phone(Required)

4. PAYMENT METHOD – Choose either PO or Credit Card

PO option

I will pay by PO

Purchase Order (PO) Number

If you are using a Purchase Order, it must have sufficient funds and not be expired in order for your order to be processed and testing to begin.

Upload PO

Accepted file types: jpg, png, pdf, Max. file size: 5 MB.

A copy of the PO must be uploaded before work can begin. EXCEPTION for uploading PO: if you have a blanket PO number and PTL has a copy on file.

Credit Card option

I will pay by Credit Card

Credit Card Number(Required)

Please call 630-403-0126 if you prefer to provide credit card information by phone.

Acknowledge service fee(Required)

I understand using a Credit Card will incur a 3% service charge.

Exp. Date

Security Code(Required)

Name(Required)

First Last

Phone(Required)

Billing Zip Code

Email(Required)

Select either:(Required)

One time use

Keep on file

Credit Card option - Call In

I will pay by Credit Card and CALL IN with my CC information.

5. SPECIAL INSTRUCTIONS

Special instructions

The PTL Quote Number should be filled in if you have received a formal price quote from our sales department. The number is shown on your quotation.

6. TELL US ABOUT YOUR SAMPLE – Check all that apply

Project Priority (subject to availability)(Required)

10 business day preliminary data turnaround = Standard

6 business day preliminary data turnaround = 50% surcharge

2 business day preliminary data turnaround = 100% surcharge

Quality System(Required)

cGMP*

ISO/IEC 17025:2017*

None

* Surcharge applies. Analyses will NOT be conducted according to cGMP or ISO/IEC 17025:2017 procedures unless specified.

Sample Return (if applicable; fees apply)

Sample ($75 minimum)

Cooler ($45 minimum)

TempTale ($45 minimum)

Sample Storage

Controlled Room Temperature

Freezer (-10 to -25 C)

Light Sensitive

Refrigerator (2 to 8 C)

Ultra Low Temp (-80 C)

Dessicator

Sample Classification

DEA** Schedule:(Required)

IIIIIIVVIINIINNDoes not apply to my material(s)

NDC#(s) Required if DEA Scheduled Sample

Biological(Required)

BSL-1

BSL-2 (Pre-approval required)

Does not apply to my sample(s)

RCRA Regulated Waste(Required)

P Listed

U Listed

High Potency (OEL of ≤10ug/m3) (Pre-Approval Required)

ATF (Pyrotechnic) **

Litigation (Additional Fees May Apply)

Does not apply to my sample

** $80/Sample handling fee. Weights and current registration required.

Submit Safety Data Sheet (SDS) with GHS Compliant Information if any of the above apply to your sample(s)

Accepted file types: jpg, png, pdf, Max. file size: 5 MB.

7. REFERENCE NUMBERS

PTL Quote #

The PTL Quote Number should be filled in if you have received a formal price quote from our sales department. The number is shown on your quotation.

Previous PTL Project

If you have previously submitted sample material for analysis, providing the PTL project number and/or test method number is helpful.

Test Method

ASTM / ISO / USP #

8. MATERIAL NAME

Material Name of 1st Sample(Required)

Your final report will use the Material Name exactly as specified in this section.

Sample ID

Your final report will use the Sample IDs exactly as specified in this section.

Analysis Requested(Required)

Material Name of 2nd Sample

Your final report will use the Material Name exactly as specified in this section.

Sample ID

Your final report will use the Sample IDs exactly as specified in this section.

Analysis Requested

Material Name of 3rd Sample

Your final report will use the Material Name exactly as specified in this section.

Sample ID

Your final report will use the Sample IDs exactly as specified in this section.

Analysis Requested

SDS Options(Required)

Not required for my material type

Analysis requested. I have uploaded my SDS above.

An SDS is not readily available.The material my sample is composed of and the appropriate personal protective equipment for handling and disposal (i.e. gloves, goggles, etc.) are indicated below.

Material handling

This form is considered PTL’s work order; by submitting samples to PTL, you agree to the Terms of Payment for services provided, including additional charges and legal fees for late payment or non-payment. In no event shall PTL be liable to client for any indirect, special or consequential damages or lost profits arising out of or related to services performed or to be performed by PTL as described herein. PTL’s liability to client hereunder, if any, shall in no event exceed the total amount paid to PTL hereunder. See service policies for additional terms of the agreement between PTL and the client which will prevail unless otherwise agreed to in writing.

agree(Required)

I have read and understood the above statement.

Please read our Terms and Conditions.

agree(Required)

I have read and understood the Terms and Conditions.

Signature/Typed name here acts as my electronic signature. I understand that my electronic signature is as valid as a handwritten signature.(Required)

Date(Required)

Submit