Authorized Signature Return at cost 10 Dispose 025sample S tore Reject s Af ter Analysis Af ter 60 days Af ter 60 days 030samplemonth Pulp s Af ter Analysis Af ter 90 days Af ter 90 days 015samplemonth Sieve Af ter Analysis Af ter 3 months Af ter 3 months 020samplemonth Irrads Af ter Analysis Af ter 30 days Af ter 30 days 020samplemonth Return Samples T o Comp any Address Attn Phone Request for Analysis Carrier W aybill of Packages of Samples Date Received T ime Received Initial Implement Environment al Sample Accept ance Form Y es NA Invoice Priority Normal may vary depending on p ackage and time of year please enquire RUSH required by Note subject to surcharge method dependent Confirmation of Sample Receipt Y es No By Email or Fax Client Info Quote PO Proforma Project Comp any Attn Address Phone Fax Email Additional Report to Comp any Address Phone Fax Email V isa MasterCard AMEX Number Expiry Date CVV Name Signature Ret ain credit card information to charge this work order and all future work orders Reporting Invoicing Instructions Report s and invoices are emailed unless otherwise indicated Invoice Hard copy 1st Address 2nd Address Report Hard copy 1st Address 2nd Address S torage Please Note License required for the return of radioactive material cost per shipment is 20000 shipping Under CFIA regulations soil sediment and veget ation samples from out side Canada require incineration prior to disposal additional charges will apply Method of Sample Return At cost client will be invoiced Our Carrier Account Carrier Name Account Phone S pecial InstructionsComment s For samples requiring Geochronology andor Isotopic Geochemistry please be sure to include the following information Rock type Minerals to be sep arated specify Estimated age Activation Laboratories Lt d 41 Bittern S treet l Ancaster ON l L9G 4V5 l T el 905 648961 1 l Fax 905 6489613 l T oll Free 1888ACTLABS l Email samplereceptionactlabscom Method of Payment Payment is included make cheque or bank draf t p ayable to Activation Laboratories Lt d Charge to credit card please ensure that complete credit card information is provided or use credit card on file Credit has been est ablished with Activation Laboratories Lt d refer to Actlabs Credit Application Form Payment will be issued af ter invoice has been received Page 1 of