Name

Job Title

Organisation

Address

City/Town

Postal/ZIP Code

Country

Region

Telephone

Fax

E-Mail

Address

Postal/ZIP Code

Country

Region

No. of Samples

Type of Samples (e.g. Drill Core, Stream Sediments, Soil Samples)

Are these Sample Prepared?

If No, do you require sample preparation?

If your unprepared samples are to be sent, what is the average wight per sample:

Please provide main elements of interest

Please provide any further information or outline any additional services requirements you may have:

Please indicate whether you would like to receive such information *