INSTITUTE OF ENVIRONMENTAL SCIENCE AND RESEARCH LIMITED
Christchurch Science Centre: 27 Creyke Road, Ilam, Christchurch 8041 | PO Box 29181, Christchurch 8540, New Zealand
T: +64 3 351 6019 F: +64 3 351 0010
BUSINESS NAME AND ADDRESS FOR REPORT AND INVOICE
BACKGROUND INFORMATION ON SAMPLE
SAMPLE INFORMATION
WHAT YOU WOULD LIKE US TO TRY TO DO
Business name:
Sample ID(s):
Number of items submitted and their description:
Address:
Date sent to ESR:
Date collected:
Would you like photographs taken? Yes No
CONTACT DETAILS
Phone:
Email:
Purchase order number:
Contact name:
Standard (<15 working days)
Urgent – 100% premium (2–3 working days)
Price estimate (if known): $ __________________ + GST
Rush – 50% premium (<8 working days)
REQUESTED TURNAROUND TIME*
*We will do our utmost to achieve these, however due to the nature
of the work, it may not be possible. Our ability to perform Rush and
Urgent will be conrmed on receipt of this form.
SEND SAMPLES TO:
Food Chemistry Laboratory
ESR, Christchurch Science Centre, 27 Creyke Road,
Ilam, Christchurch 8041
Date received at ESR:
LABORATORY SERVICES REQUEST FORM
FOOD FORENSIC INVESTIGATION REQUEST
INSTRUCTIONS FOR USING THIS FILLABLE FORM:
In Acrobat Reader DC, please complete this form, then ‘SAVE AS PDF’
to your hard drive. Email your form to Chemistry@esr.cri.nz and print
a copy to accompany your sample.
ESR0502
vers 2.0 Oct 2017
www.esr.cri.nz
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