* A purchase order or prepayment is required before testing can be scheduled.

Requestor Information (required)
Company Name:
Contact Person:
Telephone:
Email:
Back-up Contact (Optional):
Telephone:
E-Mail Test Results To:
Requested Completion Date:
Send Invoice to (A/P Contact):
Customer Reference/Project Number:
Payment Method (required)
Quotation required? Yes No *Purchase order #: A copy should be submitted to PTI.
Amount: $ Date:
Credit Card? Yes No
We are no longer collecting/storing credit card information. At the time of invoicing, we will send a link for you to enter your credit card information.

Please complete and submit samples to:

Vickie Davis Kim Harbert Kara Belcher Jodi Green

PTI

1440 Timberwolf Dr

Holland OH 43528

419-867-5420

**If shipping USPS, please add P.O. Box 964**

(This Form Must Accompany All Samples)

Please list each sample separately. (Attach additional sheet if necessary)
Sample Description	Sample Quantity	Requested Analysis

*Please provide any additive or colorant content greater than 1% if requesting Solution IV testing.

Special Instructions for sample testing or conditioning:

*Please include a part drawing and number of cavities, if applicable:

PTI will hold untested samples for a period of one week after testing is completed (unless otherwise instructed by the client). After this time, PTI will dispose of the samples to its discretion. Tested samples may not be retained, unless previously arranged.