SAMPLE SUBMISSION FORM

Date

PO/CC

Company Name

Phone

Contact Person

Address

R&DRegulatory Submission to FDAProduct/Raw Material Regulated by FDAOther

If Other

Sample Identification	Lot #	Analysis Requested	Specification (Required to avoid extra R&D fees)	Analysis Method if any

DiscardReturn (Please provide the shippingdetails)

Special Requirements:

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