Customer Information Form | TRELFA LABS, INC.

Why are you contacting us today? *

I'm a new customer.
I'm a current customer, updating my contact information.

Company Name *

Parent company / company responsible for payment.

DBA Company Name (If Applicable)

Doing Business As / alternate business name.

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Manufacturing or Retail Address (If Different from Billing)

Address Line 1

Address Line 2

City

State

Zip Code

Website URL

Company Type *

Briefly describe your product line(s):

Main Contact Person: Full Name *

First

Last

Main Contact Person: Title/Position *

Main Contact Person: Email *

Main Contact Person: Phone *

Accounts Payable Person: Full Name *

This person will be copied on test results via email unless you instruct us to remove them.

Accounts Payable Person: Title/Position *

Accounts Payable Person: Email *

Accounts Payable Person: Phone *

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

This person will be copied on your test results via email.

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

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

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

Information Additional Person Should Receive

Test Results, Completed Projects
Invoices

Dairy Clients Only: Board of Health Contact Person: Full Name

Your local Board of Health inspector will be copied on your test results via email.

Dairy Clients Only: Board of Health Contact Person: Email

Dairy Clients Only: Board of Health Contact Person: Phone

Check all services of interest. *

How often will you generally submit samples?

If you need routine testing, please indicate which days.

You must notify the lab of any changes in your sampling schedule. Failure to provide samples for scheduled pickups are subject to a $30 minimum fee.

How will you deliver your samples to the lab?

We will ship our samples.
We will call ahead to drop off our samples.*
(LOCAL ONLY) Please add us to your driver's regularly scheduled (monthly) pick up route.**
(LOCAL ONLY) Please call us to discuss a time your driver can pick up. Your predetermined route schedule does not work for us.***

*Free parking. Semi-trucks welcome. First floor access. Company signage on entry door only. **All laboratory pickups incur driver fees. See Driver Route Schedule for predetermined pickup routes. Fees vary based on your area and needs. *** As needed pickups subject to availability and incur higher fees.

Check all routine on-site sampling needs, if applicable.

Local Clients Only: Who will collect on-site samples?

Trelfa Labs' Technician
Your Company Employee

Briefly describe your on-site sampling needs including routine schedule, if applicable.

Exampe: 20 swabs/month, 10 air plates/quarter

Dairy Clients Only: Please indicate the months you require testing for your season. Examples: May - October, Year Round, etc.

You must notify the lab of any changes in your sampling schedule. Failure to provide samples for scheduled pickups are subject to a $30 minimum fee.

Please indicate visitor/parking instructions for your facility, if applicable.

Preferred Payment Method *

Pay from invoice (using credit card or ACH/e-check)
Pay via bank transfer (using ACH)
Authorize Trelfa Labs to automatically make payments on your behalf (as needed)
Mail check or US money order
Pay via phone (using credit card or ACH/check)

Please let us know how you found us, including who referred you, a web site search, or other means. *

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

Date / Time *