New Customer ELITE Legionella Enrollment Form

Enrollment Information

Enrollment Information

This request is for enrollment year: *

Contact Information of person completing this form

Contact Information of person completing this form

Facility Name *

Contact Name *

Phone *

Example: 123-456-7890

Email *

Type of Testing Site For This Order

Type of Testing Site For This Order

Select Type

Indicate "Other" type of testing here

Shipping Information

Shipping Information

Facility Name *

Contact Name *

Address

Apt, suite, etc.

Country

City

State

Zip code

Phone *

Example: 123-456-7890

Fax

Email *

Billing Information

Billing Information

Check here if same as shipping information

Facility Name

Contact Name

Address

Apt, suite, etc.

Country

City

State

Zip code

Phone

Example: 123-456-7890

Fax

Send Reports To

Send Reports To

Check here if same as shipping information

Facility Name

Contact Name

Address

Apt, suite, etc.

Country

City

State

Zip code

Phone

Example: 123-456-7890

Fax

Order Information

Order Information

ELITE Legionella Annual Proficiency

Item#: PT08500 - Price: $544.00*

*Additional international shipping fees will be added for any laboratories located outside of the 50 United States.

Payment Information

Payment Information

Purchase Order (PO#) - optional

VISA/MC: If you wish to pay by credit card, please wait for your invoice for instructions.

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