Robisan Laboratory,
Inc. 6502 E. 21st St. Indianapolis, IN 46219
Phone (317)353-6249 Fax (317)917-2379
certificate# 1441-01,1441-02
Group B 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 Information: Contact Name:Phone:Ext.:
Company Name:e-mail:
Address:
City: State:Zip:
Rework Simulation, MIR, and DWV (2 "E" and 2 "A" Coupons): Month/Year Testing Represents:Specification:
Part# (s):Lot# (s):
Date Code (s):S/N's:
Material:Number of Layers:
Resistance to Solvents (3 Samples with ink): Part# (s):Lot# (s):
Date Code (s):S/N's:
Peel Strength (Bare Copper, 8 total from 2 Lots): Part# (s):
Lot# 1:Lot# 2:Date Code:
S/N's: Will this testing be reported to DSCC in annual
report? Yes
No
Billing Instructions: Attention:Address:
