New Customer Form – TRELFA LABS, INC.

Company Name *

DBA (If Applicable)

Company Address *

Address Line 1

Address Line 2

City

State

Zip Code

Website / URL

Company Type *

Main Contact Person: Name *

First

Last

Main Contact Person: Phone *

Main Contact Person: Title *

Main Contact Person: Email *

Accounts Payable Person: Name *

Accounts Payable Person: Phone *

Accounts Payable Person: Email *

Additional Person to Receive Results/Invoices (If Applicable): Name

Additional Person to Receive Results/Invoices (If Applicable): Phone

Additional Person to Receive Results/Invoices (If Applicable): Email

Information Additional Person Should Receive

Check all services of interest. *

How do you generally submit samples?

How often do you generally submit samples?

If you need routine testing, please indicate which days.

If you would like the lab to pick up your samples, please indicate parking/pick up instructions.

Would you like to authorize Trelfa Labs, Inc. to process your credit card for payments on your behalf? *

Please let us know how you found us, whether by referral, web site search, or other means. *

Please list any additional comments, recommendations, or requirements below.

Date / Time *