Login (or register as a new user) to have your form auto populate contact information. Submit Form Sample Submission Form Step 1 of 3 33% ID or Claim Number*Sample identification unique to the submitting companySample Description*E.g. "Insect in bread product."Type of Testing Required*Please, provide a detailed description about your sample and your testing needs. Contact NameCompany Name*First Name*Last Name*Billing AddressStreet Address*Address Line 2City*State*Zip*Shipping Address the Same?*YesNoShipping AddressShipping Street Address*Shipping Address Line 2Shipping City*Shipping State*Shipping Zip* Contact InformationPhone*FAXEmail* Required Turn-Around Time*Results will be reported within the specified time frame. Please, contact us for service pricing. Standard - 2 weeks maxPremium - 1 week maxExpedited - 24 hours maxDo You Require A Shipping Kit?*A shipping kit is an insulated cooler that can be used to retrieve a sample. It includes ice packs/dry ice, detailed instructions, a return label, and a chain of custody document. NoYesPick Up Address*This is where the sample is to be retrieved. Return Service*Will the sample be returned to the shipping address when analysis is complete?YesNoDestroy After 30 DaysReturn Address*The sample will be returned to this address when analysis is complete. Would you like to register an account with us?YesNoUsername*Please choose a unique username to log in with. Before submitting this form, please add the email address, info@cibotechlabs.com, to your contact list to insure delivery of your confirmation email.Password* Enter Password Confirm Password CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.
