Group A or Miscellaneous Testing Submission Form

Please fill, print, and send this form with your order.  THANK YOU !

Information in RED is required before testing can begin.

Purchase Order (We Accept VISA and MasterCard):

Company/Coupon Information:

Contact Name:  Phone:  Ext.:

Company Name:  e-mail:

Address:

City:  State:  Zip:

Specification or Name of Test:

Part Number:

Lot Number:

Date Code:   S/N's:

Material:   Number of Layers:   Quantity of order:

Would you like the test report faxed?  Yes    No

Fax Number:

Billing Instructions:

Attention:  Address:

City:  State:  Zip: