Enrollment Form for PT08600 Wastewater Surveillance - Pathogens

Please fill out and submit this form for enrollment in the Wastewater Surveillance – Pathogens Proficiency Testing Program.

For questions regarding Item# PT08600, please contact WSLH PT customer service at ptservice@slh.wisc.edu or by calling (800) 462-5261.

Please enter the contact information of the person completing this form

WSLH PT ID (7 digits)

Current/previous account ID (if known) Please leave blank, if not known.

Facility Name(Required)

Name(Required)

First Last

Phone(Required)

Example: (123) 456-7980

Email(Required)

Facility Name(Required)

Name(Required)

First Last

Address

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

Phone(Required)

Example: (123) 456-7890

Fax

Email(Required)

Please check if same as General

Please check if address same as the General (Send To) section

Facility Name(Required)

Contact Name(Required)

Address(Required)

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

Phone(Required)

Example (123) 456-7890

Fax

Email(Required)

Please check box below for enrollment in program, then click Submit if all other information is correct.

Item# PT08600

Item# PT08600 Wastewater Surveillance - Pathogens

WSLH Proficiency Testing