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 conrmed 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
RESET FORM
