SOIL, WATER AND PLANT TESTING LABORATORY
ROOM A-319, NATURAL AND ENVIRONMENTAL SCIENCES BUILDING
FORT COLLINS, CO 80523-1120 Phone 970-491-5061/Fax 970-491-2930
NAME
	Customer/Contact					Business
CUSTOMER ADDRESS:
						Street/P O Box
			City				State		Zip code
		Customer Phone No.:				Customer Fax No.**
** Please provide this information so that results can be provided without delays for mailing and billing times.
E-Mail if available___________________________________________________________________________
ON-CAMPUS CUSTOMER BILLING INFORMATION
			Name of Department to be billed:
			Account Number:
(Students) Instructor/Advisor Name:
OFF CAMPUS CUSTOMER BILLING INFORMATION
Please do not pay by check until you receive an invoice.
Complete information for payment by credit card-
MasterCard		Name on Card						Expiration Date
Visa		Card Number						V Number **
**V number is located on the back of the card on the signature line, the last three numbers.
PO number, Project name/number needed to be seen on invoice:__________________________________________
By accepting service or goods, I agree to submit payment in full to Colorado State University upon receipt of invoice or University
Billing Statement. Late payment charges of 1.5% per month and other penalties specified may be addressed for late payment.
PRICES ARE SUBJECT TO CHANGE WITHOUT NOTICE								MINIMUM CHARGE $12.00
		DATE SUBMITTED:	_____/_____/_______				DATE NEEDED:	_____/_____/_______
LAB NO.			YOUR SAMPLE ID					ANALYSIS REQUESTED
for lab use only
TOTAL NUMBER OF SAMPLES:
SAMPLE DISPOSAL INFORMATION: Return to Originator______________ OR Destroy__________
Due to lack of storage space, the lab must discard samples 30 days after the customer receives results. If samples need to be returned, please
pick-up or arrange for return prior to that time. If samples or containers need to be returned by mail, postage and handling fee will be assessed.
CHAIN OF CUSTODY (IF NEEDED)
		Printed Name			Signature			Date	Time
Relinquished by:
Received by:
Send to: (U.S. Mail) CSU Soil, Water & Plant Testing Laboratory, NESB Room A-319 Fort Collins CO 80523-1120
For other carriers please add: 200 West Lake Street below CSU Soil, Water & Plant Testing Lab
Visit our web site at: http://www.extsoilcrop.colostate.edu/SoilLab/soillab.html (please note address is case sensitive)