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Ship samples to:
Synergy Science Solutions
4290 Bells Ferry Rd
Ste 134-23
Kennesaw, GA 30144
samples@synergysciencesolutions.com
(678) 744-4184

ANALYSIS REQUEST & CHAIN OF CUSTODY RECORD

SAMPLER INFORMATION
SAMPLE INFORMATION

Enter the batch/lot number shown on the product label. Add your sample ID if you use a different sample or container reference. Product and batch/lot details are optional; a description is enough when the product is unknown. Synergy assigns its own lab ID after receipt.

SAMPLE DATE YOUR SAMPLE ID (IF DIFFERENT) PRODUCT NAME (optional) BATCH/LOT NUMBER (optional) SAMPLE DESCRIPTION SAMPLE SIZE/UNITS ANALYSIS REQUESTED
METHOD OF SHIPMENT:
1.
2.
3.
Custody transfers and receipt details (optional)
CHAIN OF CUSTODY
RELINQUISHED BY: DATE TIME RECEIVED BY: DATE TIME SIGNATURE
CONDITION OF SHIPMENT UPON RECEIPT:
1.
2.
3.
Request Analysis

Before You Send Samples

Submission of samples under this Chain of Custody indicates acceptance of our Terms & Conditions of Laboratory Services.

Review the terms before shipment so your team has the latest billing, receiving, storage, reporting, and liability information.

How to Save as PDF

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  2. Select Save as PDF in your browser print destination options.
  3. Save the completed form for your records or shipment packet.