NATIONAL CENTRE FOR RADIATION SCIENCE
LABORATORY SERVICES REQUEST FORM
A certicate will not be issued unless the following information is provided and is clearly legible.
All information provided in this section will be exactly duplicated on the certicate.
If an additional statement is requested, documentation may be required. Please contact ESR for further information. ESR can also assist if a
certicate requires translation.
Alternative title for certicate (if required):
Goods description and quantity:
Exporters name and address:
Letter of credit number (if applicable): Other identifying number:
Customer declaration (if required):
Postal address: Post code
Phone number: Mobile:
ESR USE ONLY
INSTRUCTIONS FOR USING FILLABLE FORMS: In Acrobat
Reader, please complete this form, then save the pdf to your
hard drive. Email this form to
vers 4.0 FEB 2017
INSTITUTE OF ENVIRONMENTAL SCIENCE AND RESEARCH LIMITED
NATIONAL CENTRE FOR RADIATION SCIENCE, 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
I declare this product is of 100% New Zealand origin. YES NO (A certicate will not be issued unless this declaration is made)
If no, the goods must be tested for radioactivity content – please also complete a Testing of Foodstuffs request form.
Name and position: Date:
I agree to pay the charges incurred in obtaining this certicate
Is courier despatch required? YES NO If yes, there will be an extra charge. If no, certicate(s) will be delivered by FastPost.
A certicate will be issued within 2 working days after receipt of a request.
Number of additional copies (Additional copies are an extra charge).
Purchase order number: