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University of Wisconsin Crest

WSLH Proficiency Testing

Wisconsin State Laboratory of Hygiene

Customer Change Form

Enrollment Information

This request applies to the following:(Required)

Identification Information

Current/previous account ID (if known)
If application in progress, enter "Pending"

Contact Information

Please enter the contact information of the person completing this form
Name(Required)
Example: (123) 456-7890

Request To Add And/Or Drop Products

Add/Drop Product
Please add the product name and item # here, and separate both entries with a "/"
Add/Drop Product
Please add the product name and item # here, and separate both entries with a "/"
Add/Drop Product
Please add the product name and item # here, and separate both entries with a "/"
Add/Drop Product
Please add the product name and item # here, and separate both entries with a "/"
Add/Drop Product
Please add the product name and item # here, and separate both entries with a "/"
Add/Drop Product
Please add the product name and item # here, and separate both entries with a "/"
Add/Drop Product
Please add the product name and item # here, and separate both entries with a "/"
Add/Drop Product
Please add the product name and item # here, and separate both entries with a "/"

Add Products: Payment Information

VISA/MC: If you wish to pay by credit card, please wait for your invoice for instructions

Dropped Products

All cancellations must be submitted in writing at least 30 days prior to scheduled shipment date. A credit will be applied to your account, if appropriate. The annual processing fee is non-refundable. Refund requests will be handled on a case by case basis by the accounts receivable department.
Reason for drop

Request To Update Correspondence/Demographic Information

Change Pertains To (check all that apply)
Name
Address
Example: (123) 456-7890

Request To Update Accreditation Agency(ies)

Add/Remove Accred. Agencies
DD slash MM slash YYYY
Add/Remove Accred. Agencies
DD slash MM slash YYYY
Add/Remove Accred. Agencies
DD slash MM slash YYYY

Score Transmission To Accreditation Agency(ies)

All applicable scores will be sent to designated agencies by default unless specified below.