Chain of Custody Form

Please complete this form and return to courier@americannalab.com

P.O. Number: Tracking Number:

SENDER SAMPLE INFORMATION

Company: Sampled by:
Address: Date Sampled:
City: Total # of Samples:
State: Zip Code: Sample Type:
Contact Name: TURN A ROUND
Phone: Standard: Rush (1.5x):
E-mail: Critical (2x):

CHAIN OF CUSTODY
Request Submitted by:
Printed name Signature Date

Client Signature @ Pickup:

(if different than requester) Printed name Signature Date

Courier Signature:
(NA if dropped off or shipped) Printed name Signature Date

SAMPLE INFORMATION
Sample Description (include Lot #) Test(s) to be Performed Comments

FOR INTERNAL USE ONLY

Received by: Date: Sample Arrival and Check-in

Comments/Conditions: Date:
Time:
Initials:

Americanna Laboratories, LLC

11757 Central Pkwy | Jacksonville, FL 32224
FORM: ADN357.0 (904) 549-5948 | www.americannalaboratories.com Page 1 of 1