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P.O. No (Required for test to be scheduled) _________Quote No: __________Date Sent:_______

Company:______________________________   Address:_______________________________

City, State, Zip:________________________________________________________________

Phone:_____________Ext. _____      Fax: (Confirmation will be faxed to this #)________________

Contact: ________________________      E-mail Address: _________________________

Authorizing Signature________________________ Printed Name: _______________________

Address Report:_______________________________________________________________

Address Billing:_______________________________________________________________

Test Required: ______________________________________________________

Samples submitted for:     [    ] Initial Testing        [    ] Retest

Specification: Do you request Gibraltar to initiate an OOS investigation if out of specification results occur?    [    ] Yes        [    ] No

Is it to be GLP?*        [    ] Yes    [    ] No            RUSH:    [    ] Yes (+100% Fee)

[    ] Client Specification     [    ] Client test Methods

Test Article Name: (Use Exact wording desired on final report) ___________________________

Lot #: ________________________         Other Identification: __________________

Description: ________________________________________________________________

Comments (Please use space below for further instructions, additional lot numbers, etc.)

_____________________________________________________GBL Number: __________

This form completed by: (Name)_______________________ (Title)___________________

GLP Note: GLP studies require three business days for protocol development. Please contact Quality Assurance (973/227-6882, Ext: 514) for assistance.

Non-GLP studies conform to the same standards as GLP except for additional administrative and record keeping requirements.

If payment is to be made by Credit Card please go to Credit Card Processing and follow directions.