New Customer ELITE Legionella Enrollment Form

Enrollment Information

This request is for enrollment year:(Required)

Contact Information

Please enter the contact information of the person completing this form

Facility Name(Required)

Name(Required)

First Last

Phone(Required)

Example: (123) 456-7890

Email(Required)

Type Of Testing Site For This Order

Select Type

Indicate "Other" type of testing here

General (Send Reports To)

Facility Name(Required)

Contact Name(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Example: (123) 456-7890

Fax

Email(Required)

Billing Information

Check here if same as General (Send Reports To)

Facility Name

Contact Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Example: (123) 456-7890

Fax

Email(Required)

Shipping Information

Check here if same as General (Send Reports To)

Facility Name(Required)

Contact Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Example: (123) 456-7890

Fax

Email(Required)

Order Information

ELITE Legionella Annual Proficiency

Item#: PT08500 - Price: $550.00*

*Additional international shipping fees will be added for any laboratories located outside of the 50 United States.

Payment Information

VISA/MC: If you wish to pay by credit card, please wait for your invoice for instructions.

Purchase Order (PO#) - optional

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WSLH Proficiency Testing

Enrollment Information

Contact Information

Type Of Testing Site For This Order

General (Send Reports To)

Billing Information

Shipping Information

Order Information

Payment Information