Sample Submission Form Shipping Address MarketFresh Laboratory 2920 Talmage Ave. SE Minneapolis, MN 55414 Website www.marketfreshlabs.com Tel 612-331-4050 Fax 612-331-4097 Company Information:: Current Customer (If Checked, Only Company Name is Required) Company Name and Address: __________________________________________________________________________ Contact Name(s): _______________________________________________________ Phone: ______________________ Email(s):______________________________________________________________ Fax: ________________________ Special Instructions or Comments: _________________________________________________________________________ Date of Sample Submission ______/_______/_______ Other: * Other: * Salmonella Listeria E.coli O157.H7: S.aureus (Coagulase +) Mold & Yeast Sample Description (Please write the description as you would like it recorded on the report.) Coliforms & E.coli APC Sample # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 *Please call or check website for additional tests available. For Internal Use Only: Received by:______ Temperature @ Receipt: ________ Condition @ Receipt: Acceptable Unacceptable Customer # ______ Package # _____________ Comments: ________________________________________________________________________________________________________________________________ MFLD802_Sample_Submission_Form Revision 1.0 Issue Date 02/01/2013 Authorized by Alison Larsson, Ph.D. Page 1 of 1 MarketFresh Labs LLC