lifeprint
DNA ANALYSI S
Test Order
Toxicological Analysis
lifeprint GmbH
Industriestrasse 12
89257 Illertissen
Germany
[email protected]
www.lifeprint.de
Please attach to your samples
Tel.: +49 (0)7303 951 95-0
Fax: +49 (0)7303 951 95-55
Test report to:
Company:
Contact person:
Address/PO Box:
Postal code:
Town/City:
Phone:
Fax/Email:
Invoice recipient (if different from customer):
Company:
Contact person:
Address/PO Box:
Postal code:
Town/City:
Phone:
Fax/Email:
Comments:
Information regarding samples (data will be included in the test report)
Sample description
Your sample code
1
2
3
4
5
6
7
8
9
10
Express-Service
24h
8h
I hereby acknowledge the latest general terms and conditions of lifeprint GmbH – a company of Tentamus Analytics GmbH –
and accept them for this and all future orders.
____________________________________________________________________________________________________
Date
Signature/Company Stamp
Mykotoxins
Sample no.
Aflatoxins B1, B2, G1, G2
Ochratoxin A (OTA)
Deoxynivalenol (DON)
Zearalenon (ZEA)
Diacetoxyscirpenol
Fumonisins B1, B2, B3
T2-/HT2-Toxin
Patulin
Nivalenol
3-Acetyldeoxynivalenol (3-AcDON)
15-Acetyldeoxynivalenol (15-AcDON)
Mykotoxin screening (one sample on 2-9 Mykotoxins; except: Fumonisins, Patulin and
Nivalenol) for the following parameters:
Heavy Metals
Sample no.
Mercury (Hg)
Cadmium (Cd)
Lead (Pb)
Arsenic (As)
Pesticides
Sample no.
Determination of pesticides (multimethod)
Glyphosat, Glufosinat, AMPA
Phenylurea (herbicide)
Dithiocarbamate (fungicide)
Chlormequat and Mepiquat
Ethephon
Maleic acid hydrazide
PAKs
Sample no.
PAH: EPA-Package (food)
PAH: PAH 4 (feed)
Benzo-(a)-Pyren
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Quaternary ammonium compounds
Sample no.
Quaternary ammonium cations: BAC + DDAC
Quaternary ammonium cations: BAC + DDAC + CPy + CTMA
Quaternary ammonium cations: BAC
Quaternary ammonium cations: DDAC
Further parameters
Sample no.
Mineral oil components (MOSH/MOAH)
Amino alcohols
BHT (2,6-Bis(1,1-diemthylethyl)-4-methylphenol)
Dioxins & PCB
Sample no.
Package: PCDD/F and dI-PCB
Package: PCDD/F, dI-PCB and ndI-PCB
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In case of an initial order please fill in the form below!
Important for correct data transfer
Reference sample for internal retestings
lifeprint GmbH, Industriestrasse 12, 89257 Illertissen, Germany has to store the reference samples received from
our company:
Company:
Address/PO Box:
Postal Code:
Town/City:
months (6 months included).
Test result or data transmission
I / We want you to send all
Test Reports:
by e-mail
by post
Invoices:
by e-mail
by post
by fax
This is valid for all future orders counting from the receipt of this letter at lifeprint.
E-mail address, if e-mail transmission is required: ____________________________________________
I am aware of the fact, that sending data via non-encrypted e-mail poses serious security risks (e.g. data becoming public via third
parties, infection by malware/viruses) and is not regarded as safe data transfer according to German law. lifeprint GmbH does not
accept liability for indirect and/or consequential damages.
VAT-ID-Number
Our VAT-ID-Number is (EU-member states only):
General terms and conditions
I hereby acknowledge the latest general terms and conditions of lifeprint GmbH – a company of Tentamus Analytics
GmbH – and accept them for this and all future orders.
______________________________________________________________________________________________
Place, date
Signature/Company stamp
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