To be completed at Charles River
LTM Order Number:
Date Received:
Microbiology Submission Form
Customer Information
* = required
Bill To Information
Same as Customer
LTM Customer ID#*
Institution*
Institution*
Address 1*
Address 1*
Address 2
Address 2
City*
City*
Zip Code*
State*
State*
Contact*
Contact*
Phone*
Phone*
Email*
Email*
Payment information required
at the time of submission.
Pay by PO
PO #
Pay by Credit Card (CC)
Contact
Phone
Zip Code*
To pay with a CC on file, indicate
the last four (4) digits and
expiration date. For CC security,
do not write the full CC number.
CC Last 4 Digits
CC Exp Date
Sample Information
To the best of my knowledge these samples and/or specimens do not contain any infectious agent or material which might pose a
threat to human health. If this is not the case, please call Charles River before sending samples.
Date:
Signed:
Please use one form per sample type.
Sample
Number
Sample ID
Ship Date:
Species (if applicable):
Total Number of Samples:
Quantity
of Samples
Facility/Room‡ Type/Strain‡
Sample Type
Service Requested
1
2
3
4
5
6
7
8
9
10
‡
If you generate summarized health reports from LTM, these fields MUST be completed for your samples to be associated with specific colonies. If left
blank, no colony information will be associated with your sample(s), and the results from this testing will not appear on the summarized health reports.
Notes:
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Shipping Instructions
Questions? LabServices@crl.com www.criver.com/info/dx
Print Form
Sample Specifications:
Samples should be shipped overnight on ice packs. Please use appropriate shipping materials and never use glass
containers.
Sample Submission:
Place a copy of page 1 in the appropriate shipping container with your samples. Please follow International Air
Transport Association (IATA) guidelines.
Charles River provides IATA-compliant sample shipping materials free of charge. Simply contact Charles River
Customer Support (North America: 1.877.274.8371, International: +800.3195.3430) to request materials for
diagnostic testing. Alternatively, you may order shipping materials via our website at www.criver.com/info/quotes.
Submit your samples to Charles River :
Charles River
RADS
Microbiology Lab
261 Ballardvale Street
Wilmington, MA 01887
USA
Charles River
RADS
327 impasse du Domaine Rozier
Domaine des Oncins
69210 SAINT GERMAIN NUELLES
FRANCE
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