Your Full Name:
Order Reference Number from the Mycotoxin Testing Lab website:
Street Address:
City, St. Zip Code:
Phone Number
Email address:
Area Sampled (example: kitchen cabinet, living room wall):
Date and time sample taken:
Name of person taking sample:
Send my results via: Email U.S.Mail Fax
My fax Number:

Print out a label for each sample; enclose in the tyvek bag with the sample.