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CHAIN OF CUSTODY RECORD
Report Information
Invoice information
Company:
Company:
Contact:
Contact:
Address:
Address:
Phone:
Phone:
Fax:
Fax:
Email:
Email:
Additional Reporting Information
Special Instructions by Client
Rush:
Please contact the laboratory to confirm rush dates and times before submitting samples.
Upon filling out this section, client accepts that surcharges will be attached to this analysis.
Date Required
Authorized Signature
KML rush Acceptance Signature
#
Sample Identification
Date Sampled
Quantity
Sample Lot Number
Test Ordered
1
2
3
4
5
6
7
6
9
10
All samples must be clearly identified and all applicable areas of the submission sheet completed. Improper or incomplete sheets may result in delayed sample processing. KML will use AOAC Official methods by default. USP and BAM methods need to requested prior to sample submission to make the necessary mediums that are required.
Relinquished by:
Received by:
Date/Time
Purpose of Change/Remarks
Please enter Security Code
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