Agdia Testing Services Sample Submission Form Agdia Incorporated Phone: 1-800-622-4342 52642 County Road 1 Fax: 574-264-2153 Elkhart, Indiana 46514 USA Email: [email protected] Please submit samples via overnight courier (Fed Ex, UPS, etc.) Sample Submitted by: Submitter's Name:_________________________________________________ Company Name:______________________________Accounts Payable Contact:___________________________ Address:_________________________________________________________ City:__________________State:_______Zip:_________ Country:__________________________ Phone:______________________Fax:_____________________ Email:__________________ Preferred contact information for results (email addresses, fax numbers):_____________________________________ Send invoice to: Check here if same as above [ ] All results are confidential to submitter. If you would like the invoice to be billed and results sent to a third party, please complete this section. Company:_____________________________ Attn: ______________________________ Address:_______________________________________________________________________ City:____________________________________ State:_______ Zip:_________ Country:_____________ Phone:_____________________Fax:____________________ Email:_________________ Method of payment: [ ] Bill to purchase order number:____________________________ [ ] Wire Transfer [ ] Check Enclosed [ ] Visa [ ] Mastercard Account Number:________________________ Exp. date:__________ Zip Code: __________ Cardholder’s Name:________________________Cardholder's Signature:_________________________ Mailing Preferences: An electronic copy of the report (email or fax) will automatically be sent to submitter. If you would like the results to also be sent by mail, please complete the information below. There is a $20.00 additional charge per mailed report. [ ] Please mail a hard copy of the final report [ ] Please mail an extra hard copy of the final report to a third party: Name:___________________________________________________________ Address:_______________________________________________________________________ City:____________________________________ State:_______ Zip:_________ Country: _____________ Sample identification: (e.g. Impatiens 'agdia medley' 001) For multiple requests use multiple forms. Sample Type Sample ID 1 6 2 7 3 8 4 9 5 10 Sample Type Sample ID Test(s) requested*: ________________________________________________________________ *If you are not sure which pathogens to test for, we recommend one of our screens. These contain tests for frequently encountered viral pathogens of a particular crop. Please feel free to call us to ask which screen suits your crop best, or check our website: www.agdia.com.