Supply Request Form

Name
Company
Street Address
Mailing Address
City
Postal Code
Email
Phone
Supplies Needed:
By Bottle:
	250 mL Sterile Plastic (with Nathiosulphate)
	250 mL  Plastic
	500 mL  Plastic
	1 L  Plastic
	1 L Clear Glass
	1 L Amber Glass
Other:
Other:
Other:
By Test: Please provide a list of tests & number of samples you need supplies for
Other Supplies: Do you require other sampling supplies (such as preservatives)?
Delivery Information: There is no cost for the sampling supplies and we provide a choice of shipment methods for your convenience.  Please note however that North Island Labs does not cover the cost of shipping supplies.
How would you like your supplies shipped?	please choose... pick up courier bus
If pick up, at which  of our locations?	please choose... Courtenay Nanaimo
If courier, please let us know which one & your account number:
Courier:
Acct No.:
If bus, where you would like to pick up supplies?
When do you need to have these supplies by?
If you have any questions regarding sampling, please contact us directly. Thank you for your time and for providing North Island Labs with the opportunity to be of service.