Eurofins QTA, Inc.
8900 Beckett Road
West Chester, OH 45069
1(866)-yourQTA
QTA On-Demand Order Form
Customer Information
Company Name:
Address:
___________________
__________________________
To whom should QTA Send Results?
Contact Name:
Email:
City, State, Zip:
___________________
Email:
___________________________
Phone:
___________________________
Fax:
_______________
____________________
_____________________
Order Details
Payment Method:
Credit Card
Check
Payment to accompany first sample or in advance.
Complete credit card authorization or mail payment to Eurofins QTA, Inc, 8900 Beckett Road, West Chester, OH 45069
Attn: Eurofins QTA On-Demand Billing
Order Quantity
# of Samples
Price per Sample
Package
Price
10
$120
$1,200
25
$110
$2,750
50
$90
$4,500
10 - Blends Only
$50
$500
This order form is for the purchase of QTA On-Demand Analysis. Customer is purchasing a package of sample analyses, packages
may be used at any interval or time frame and expire one year after purchase, if unused. Standard turnaround will consist of sending
analytical report to customer via facsimile or electronic mail within two business days of sample receipt. Payment is due in advance or
upon receipt of first sample. Packages are non-refundable.
Customer Signature
Signature
Name
Title
Date
www.qta.com │ 1(866)-yourQTA │ help@qta.com
Eurofins QTA, Inc.
8900 Beckett Road
West Chester, OH 45069
1(866)-yourQTA
CREDIT CARD PAYMENT REQUEST
Date: _________________
Customer ID: _______________________________
To:
Accounts Receivable
From:
________________________________
Company:
Eurofins QTA
Company:
________________________________
Fax:
513.693.4030
Fax:
________________________________
Phone:
513.842.3999
Phone:
________________________________
Email:
help@qta.com
Email:
________________________________
Do you need a copy of the receipt: _________ Fax _______ Email _______ USPS
Total No. of Pages Including Cover: ______
CREDIT CARD INFORMATION
Credit Card #: ___________________________________________
Cardholder Name: _______________________________________
Exp. Date: _____________________________________________
Statement Address: _____________________________________
City, State, Zip: _________________________________________
Authorized Signature: ____________________________________
Please check here if you would like your credit card billed monthly.
Invoice
Amount
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privileged material. Any review, retransmission, dissemination or other use of, or taking of any action in reliance upon, this information
by persons or entities other than the intended recipient is prohibited. If you receive this in error please contact the sender and destroy
this information.
www.qta.com │ 1(866)-yourQTA │ help@qta.com