{1}
##LOC[OK]##
{1}
##LOC[OK]##
##LOC[Cancel]##
{1}
##LOC[OK]##
##LOC[Cancel]##
Registration Form
Information requested to Open Client File
Laboratory Divison – IRSST
505, De Maisonneuve blvd West
Montréal (Québec) H3A 3C2
Phone : (514) 288-1551 ext. 306
Email:
[email protected]
Choose the language :
Français
Section I :
Company Identification
Company's name:
Department:
Address :
City/Prov. or State :
Postal or Zip :
Phone #:
Ext:
Fax :
Section II :
Administrator
Name of person in charge (admin):
Email of person in charge :
Phone #:
Ext. :
Section III :
Invoicing
Name of person in charge (invoices):
Check if name of person in charge is required on invoice:
Email of person in charge :
Check if invoice needs to be sent by email:
Invoicing email address (if different from person in charge):
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
Communal type face mask/ Respirator Filtration (N95 type) / BNQ Attestation for FPP
Others
Click "Send" to send this form to Customer Service.
Your form has been sent.
Do you want to print the form?