Completion of this form verifies that you agree to Trelfa Labs’ Terms and Conditions. Please enable JavaScript in your browser to complete this form.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 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeManufacturing or Retail Address (If Different from Billing)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWebsite URLCompany Type *CommissaryContract SanitationDairyFood DistributorFood RetailerFood Service OperatorFood/Beverage Manufacturer (sm)Food/Beverage Manufacturer (lg)Food/Beverage PackagingLaboratory (contract work)Pharmaceutical Manufacturer (sm)Pharmaceutical Manufacturer (lg)Raw Materials SupplierRestaurant / RetailStart Up IncubatorOtherBriefly describe your product line(s):Main Contact Person: Full Name *FirstLastMain Contact Person: Title/Position *Main Contact Person: Email *Main Contact Person: Phone *Accounts Payable Person: Full Name *This person will have access to test results in your Client Portal account 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 NameThis person will have access to test results in your Client Portal account. Please note that invoices can only be sent to two email accounts in your company file.Additional Person to Receive Results/Invoices (If Applicable): Title/PositionAdditional Person to Receive Results/Invoices (If Applicable): EmailAdditional Person to Receive Results/Invoices (If Applicable): PhoneInformation Additional Person Should ReceiveTest Results, Completed ProjectsInvoicesDairy Clients Only: Board of Health Contact Person: Full NameYour local Board of Health inspector will have access to your test results via the Client Portal.Dairy Clients Only: Board of Health Contact Person: EmailDairy Clients Only: Board of Health Contact Person: PhoneCheck all services of interest. *Analytical TestingFacility PlanningFood Safety AuditsFood Safety ConsultingFood Safety LiaisonFood Safety TrainingMethod ValidationNutrition Panels/LabelingShelf Life StudiesHow often do you generally submit samples?DailyWeeklyMonthlyAs NeededIf you need routine testing, please indicate which days.MondayTuesdayWednesdayThursdayFridayYou 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 do you typically deliver samples?CarrierDrop OffLab Pick UpIf you have your own fleet, please note that there is plenty of parking to accomodate large delivery trucks.Check all routine on-site sampling needs, if applicable.Dairy: Soft Serve Ice CreamDairy: Frozen YogurtDairy: GelatoSushiEnvironmental: Air PlatesEnvironmental: SpongesEnvironmental: SwabsOtherWho will collect on-site samples?Trelfa Labs' TechnicianYour Company EmployeeBriefly describe your on-site sampling needs including routine schedule, if applicable.Exampe: 20 swabs/month, 10 air plates/quarterDairy 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 orderPay via phone (using credit card or ACH/check)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 *CommentSubmit