Sample Testing Submission Form

Koehler Instrument Company, Inc.
1595 Sycamore Avenue
Bohemia, New York 11716, USA
1-800-878-9070 (USA only)
Tel: +1 631 589 3800
Fax: +1 631 589 3815

This form MUST accompany ALL samples.

In order to avoid delays, please complete ALL sections of this form; include one copy with the samples and fax one copy to Koehler at +1 631 589 3815.

Customer Information
Contact Name:
Company Name:


Sample Information
Sample Name:
Sample ID:
MSDS Included?:
Testing Required:
(Please list test method, time, temperature, material specification, and all other relevant information to complete testing.)

Payment Information
This section must be completed. Please choose either Purchase Order or Credit Card for payment.
Purchase Order
Credit Card
PO #

Amount: USD$

. MasterCard
Terms: Net 30 days .
American Express
Amount: USD$

Card Number:

Exp. Date:

Cardholder's Name:

Cardholder's Signature:

Packaging of Samples
Unbreakable containers are preferred when possible. If glass containers are used (poly-coated recommended), then they should be shipped with adequate packaging material.  Double packaging is best.  Lids should be firmly sealed and taped.  Samples should NOT be packaged in plastic bags.  Packages may be returned if integrity of sample is damaged during shipping.   Materials containing lead, chlorine or any other component restricted in the United States will be assessed additional disposal charges. Recommended sample quantities are made to reduce waste.  Excessively large samples will incur a $5.00 per kg handling and disposal fee. 
International Shipments
In order to avoid additional charges due to the need for a courier through customs, a carrier that will deliver directly to our lab, such as DHL, should be used.  Material Safety Data Sheets (MSDS) should be included with samples as well as all required paperwork for international shipping. 
Ship Samples To:
Koehler Instrument Company, Inc.
ATTN: Neda Babinsky
1595 Sycamore Avenue
Bohemia, New York 11716, USA