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Section I :

Company Identification

Company's name:  
Department:
Address :  
City/Prov. or State :   Postal or Zip :  
Phone #:   Ext:
Fax :

Section II :

Administration

Person in charge :
Email :
Phone #: Ext. :

Section III :

Invoicing

Person in charge :  
Email :    
Phone #:   Ext. :

Section IV :

Invoicing address (if different from section I)

Department:
Address :
City/Prov. or State : Postal or Zip :
Phone #: Ext:
Fax :

Section V :

Names of Laboratory Services' Requesters

Name, First Name

Title

Email

Phone #:

Ext.

Please select services that are expected to be requested

ENVIRONMENTAL Analyses (Industrial Hygiene)
TOXICOLOGICAL Analyses
MICROBIOLOGICAL Analyses
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