Assayed Sample Sets Order Form - WSLH Proficiency Testing

Enrollment Information

This request is for enrollment year:(Required)

Identification Information

WSLH PT ID (7 digits)

Current/previous account ID (if known)

CLIA ID

If application in progress, enter "Pending"

Contact Information

Please enter the contact information of the person completing this form

Facility Name(Required)

Name(Required)

First Last

Phone(Required)

Example: (123) 456-7980

Email(Required)

Billing and Shipping Information

Please provide your billing and shipping information ONLY if you are a new customer or information is different than your PT enrollment.

New Customer or PT Enrollment info is different

Select if new customer

Select if information is different than PT enrollment

Billing Information

Fill in ONLY if new customer or information is different than PT enrollment.

Facility Name

Contact Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Example: (123) 456-7890

Fax

Email(Required)

Shipping Information

Fill in ONLY if new customer or information is different than PT enrollment.

Facility Name(Required)

Contact Name(Required)

Address(Required)

Check box if address is same as billing address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Example (123) 456-7890

Fax

Email(Required)

Order Information

To order Assayed Sample Sets enter quantity.

PT07010

HIV (VSHV)

Price: $210.00

PT07020

Blood Lead 3 Samples - (VSBL)

Price: $146.00

PT07030

Blood Lead 5 Samples - (VSPB)

Price: $210.00

VSPB - Select Instrument

Express Shipping

Order Total

Payment Information

Purchase Order (PO#) - optional