On-line Sample Submittal Form

273 Mulberry Drive, Suite 9 • Mechanicsburg, PA 17050
(717) 697-7536 • (717) 697-4800 (fax)

Contact Us

sample submittal form

Instructions

Please fill out the on-line form below as completely as possible. If you prefer to complete the form by hand and return it by regular mail, you may download a copy by clicking here.

The more information we have, the better we will be able to provide your results quickly and precisely.

Chemical Solutions Ltd. contact information is provided at the bottom of the form. If you need any assistance, please do not hesitate to contact Bernadette Galinskie, sample custodian, at 717-697-7536 or email her at bgalinskie@chemicalsolutionsltd.com.

Mandatory fields are indicated by an asterisk ( * ). If you need HELP with a specific field, click here for a pop-up help page.

*Name:

*Company:

*Address:

Address2:

*City:

*State:

*Zip Code:

*Telephone:

Fax:

*Email:

P.O. Number:

Project:

If Billing Contact Info is different, please complete:

Name:

Company:

Address:

Address2:

City:

State:

Zip Code:

Telephone:

Fax:

Email:

P.O. Number:

Project:

Sample
ID # Matrix/
Product Analysis(es) Expected Value
(give units)

Precautions:

Comments:

How Shipped: Date Shipped:

Upon successfully submitting this form, you will be redirected to our home page. Shortly thereafter, you will receive an email message confirming our receipt of your electronic Sample Submittal Form.