Samples Received 
                                 (Date & Time):                                                                           By: 
                                                                                             Sample Storage:    Lab    Freezer    Refrigerator    
                                 Currier:  DHL    FedEx    UPS    USPS  Walk-In    Other:    Other:
                                 Samples/PO Received 
                                 (Date & Time):                                                                           By: 
                                 Samples Returned 
                                 (Date & Time):                                                                           By:
                                      MSDS INCLUDED:               Hazardous Samples:             Return Samples:              Return Cooler:
                                          YES  /  NO                    YES / NO                    YES  /  NO                   YES  /  NO
                                 DUE DATE:                                                   PCL PROJECT #:
                                                                             For PCL Office Use Only
                 Particle                                                                                Sample Submission 
                Form
                Characterization Laboratories, Inc.
                        PLEASE SIGN FORM AND INCLUDE YOUR PURCHASE ORDER OR PROCARD NUMBER WITH SAMPLES
                       COMPANY:               
                 Invoice Contact:             
                                                                                                               Shipping Instructions
                          Address:            
                   City, State, ZIP:                                                  Please ship samples to:
                                                                                                   Particle Characterization Laboratories, Inc.
                           E-mail:                                                                               845 Olive Avenue
                                                                                                                 Novato, CA 94945
                           Phone:                                                                 Phone (415) 893-1113; Fax (415) 893-893-0132
                              Fax:                                                    Important:  Please ship via. FedEx, UPS, DHL, California Overnight, or 
                                                                                      other carrier that allows for electronic tracking of the package.  Please e-
                          Quote#:                                                     mail us the tracking number at sales@particleanalysis.com.
                                                     (if applicable)
                 PO/Credit Card#:             
                                                                                               Signature:
                  Card Exp. Date:             
                   Card Signature:                                                                                   Required
                  Special Invoice Instructions           
                                                                  Sample Processing Information
                                                                          Sample Information
                SAMPLE           Standard    (e-mail data within 5 business days)               Rush not available for all analyses
                PRIORITY                                                                        Please call to inquire
                SAMPLE TYPE                  SAMPLE ID#                           # of          ANALYSIS REQUESTED            CLASSIFICATION:
                STATUS           100% Rush / 100% Surcharge                       SAMPLES                                         Normal
                                           (e-mail data within 3 business days)                 Hardcopies of data will be FedEx Priority Overnight
                                                                                                                                  Hazardous*
                                 cGLP / 100% Surcharge                                                                        (MSDS Required)
                                           (e-mail data within 10 business days)
                                                                                                         
                                                                                                                              STORAGE:
                By submitting samples to PCL you (the client) agree to the terms of payment for services provided, including additional charges and legal fees for late payment or non-
                Return           YES*     Additional $35 min. fee (FedEx Ground)
                                                                                                                                  Ambient
                payment.  In no event shall PCL be liable to the client for any indirect, special or consequential damages or lost profits arising out of or related to services performed or to
                Samples?         NO       *MSDS Required for Hazardous samples–additional shipping charges may apply
                be performed by PCL as described herein.  PCL’s liability to the client hereunder, if any, shall in not exceed the total amount paid to PCL.  The agreement between PCL
                                                                                                                                  Refrigerator
                and the client shall be deemed to have been performed in its entirety in the State of California and shall be interpreted in accordance with the laws of the State of
                                                                                                                                  Freezer
                California.                                                                                                       Light Sensitive
                                                                                                         
                                                       PLEASE INCLUDE MSDS WITH SAMPLES WHEN POSSIBLE