ALTECA, Ltd. - Submit a Sample

ALTECA Ltd. Sample Submit Form
ALTECA Home | Instructions on Submitting a Sample | Blank Submit Form | Rapid Ready Shipping Service

Please fill out this form and click on the SUBMIT button at the bottom (* Indicates a required field). The submit form will be E-mailed to us and a confirmation page will appear on your screen. Please print a copy of the confirmation page for your records. Please also include a copy of the confirmation page in the box with your sample.

HINT: Use the tab key to move in between fields.

If you prefer to have a Sample Submit Form e-mailed to you (in Word or WordPerfect format) so it can be filled out and e-mailed back to us, please send your request via E-mail.

CONTACT INFORMATION:
Please make sure that we have complete contact information for the person submitting the sample, the person(s) who should receive a copy of the results, the persons with whom we may discuss results, and to whom the invoice should be sent. The party responsible for paying the invoice also controls the custody of the sample, including who is authorized to discuss sample results. We will not discuss results with unauthorized persons. If you want to include any additional information that won't fit on this form, please fax it to (785) 537-1800 or email us.

Please also read and follow our Instructions for Submitting a Sample for Microscopic Examination.

Report Results to:

Name*
Organization*
Street Address*
Address (cont.)
City*
State/Province*
Zip/Postal Code*
Work Phone*
FAX*
E-mail*
URL

Report Results via*:
Fax (Results will be faxed unless otherwise indicated.)
E-mail
Verbal Only; no written report to be issued.

Send Invoice to: Same as Report Results Address Above

Name*
Organization*
Street Address*
Address (cont.)
City*
State/Province*
Zip/Postal Code*
Work Phone*
FAX
E-mail

* Indicates required fields if Invoice is not the same as Reports Results

Purchase Order #:

This form was completed by:

Name*
Title*
Organization*
Date*

SAMPLE INFORMATION:
fill in all that apply:

Claim Number/Lot Number *:
Claimant's Name:
Date of Incident:
Specific Product Involved:
Restaurant/Retailer where product was purchased*:

Detailed Description of the material to be identified *:
i.e. glass, bone, blood, black spot, hair, etc. - DO NOT write 'foreign material'; be specific!

Provide a brief narrative of the circumstances surrounding this sample:

Services Desired *: (Please select which type of microscopy and any additional options desired)

Qualitative Microscopy

Identification of the foreign material

$275 per hr. (1 hr min / 30 min increments thereafter)

Includes: Qualitative analysis with short report.

Available Options (Addt Costs Apply):
Cook Testing ($25)
Blood Residue Analysis ($50 per test)
Saliva Residue Analysis ($50)
Full Written Report ($75)
FTIR Analysis ($75)
SEM/EDX Analysis ($200/hr : $100 minimum)
Photo Documentation ($100)

Forensic Microscopy

Identification of the foreign material and determine, if possible, when/how it entered the product.

$350 per hr. (1 hr min / 30 min increments thereafter)

Includes: Qualitative and forensic analysis with full written report and appropriate forensic tests (cook testing, blood residue analysis, saliva residue analysis, SEM/EDX Analysis and FTIR Analysis).

Available Options (Addt Costs Apply):
Photo Documentation ($100)
Video Documentation (call (785) 537.9773 for a quote)

Sample Storage * (read our sample storage policy):

Destroy after analysis; all samples will be destroyed after 60 days, unless otherwise indicated.
Long-Term Frozen Storage; freezer space may be rented at the laboratory; Call the lab for details.
Return Sample after analysis: a return charge will apply. Provide the complete physical address and telephone number below.

Return SampleTo: Return Sample to Same Address as Results

Name*
Organization
Street Address*
DO NOT USE A P.O. BOX ADDRESS!
Address (cont.)
City*
State/Province*
Zip/Postal Code*
Telephone #*

* Indicates required fields if Return Sample is not the same as Reports Results

Priority:

Standard (6 weeks)
RUSH (5 business days) - Rush service is billed at an additional $150 per hour
SAME DAY RUSH - Service is billed at an additional $300 per hour; prior arrangements must be made for this service; call the laboratory at (785) 537-9773.

Additional Options: (Check all that apply)

NON-DESTRUCTIVE TESTING (See Non-Destructive Testing explanation on our Forensic Food Microscopy page)

CHAIN OF CUSTODY RECORD; include your form with the sample, or see our chain of custody information.

RAPID/READY SHIPPING KIT; a shipping kit should be shipped by ALTECA to the following person/company. Include a contact person's name, company (if applicable), complete shipping address (NO P.O. BOXES), and telephone number.For details about this service, visit our Rapid/Ready Shipping Service page.

Estimated size/dimensions of the sample:
Rapid/Ready Priority:
Standard Shipping (UPS/Ground)
RUSH Shipping (UPS/Next Day Air)

Make any further notes or comments here:
Be sure to let us know if the party shipping the sample is different from the contact information above, so that we can match your submit form to the sample when it arrives.

Ship samples to ALTECA Ltd., 731 McCall Road, Manhattan, KS 66502
Tel: (785) 537-9773, Fax: (785) 537-1800, Click here to send us an E-mail

I understand that by clicking on the Submit Form button below, I am ultimately responsible for the charges incurred during the testing, consulting, and/or examination of the above referenced sample.

PLEASE CLICK THE 'Submit Form' BUTTON BELOW.DO NOT JUST PRINT THIS PAGE FROM YOUR BROWSER. AFTER YOU SUBMIT THE FORM, YOU WILL RECEIVE A CONFIRMATION PAGE THAT YOU CAN PRINT FOR YOUR RECORDS. PLEASE ALSO INCLUDE A COPY OF THE CONFIRMATION PAGE WITH YOUR SAMPLE WHEN YOU SHIP IT TO THE LAB.

Name*
Organization*
Street Address*
Address (cont.)
City*
State/Province*
Zip/Postal Code*
Work Phone*
FAX*
E-mail*
URL

Name*
Organization
Street Address*	DO NOT USE A P.O. BOX ADDRESS!
Address (cont.)
City*
State/Province*
Zip/Postal Code*
Telephone #*
	* Indicates required fields if Return Sample is not the same as Reports Results