Lab Account

Contact Information

Company/Account Name*

Phone*

Primary Contact*

Fax

Email*

Shipping Address*

City*

County*

State*

Zip Code*

Have you already contacted the lab? * Yes No

If you have already contacted the lab, please note who you talked to in the Additional Notes at the end of this form.

Billing Information

Same as Shipping Address* Yes No

Billing Phone*

Billing Contact*

Preferred Billing Method* Mail Email Both

Invoice Email Address*

Billing Address*

PO Required* Yes No

Invoice Frequency* Monthly (Standard) Bimonthly Weekly

City*

County*

State*

Zip Code*

Primary Industry

Primary Industry*

Primary Product(s)/Service(s)

Company Website

Type and number of Samples to be analyzed annually

Soil		Plant tissue		Water		Compost
Manure		Fertilizer/lime		Nutrient solution		Feed

Report Contacts

(People who should receive reports)

If you are using a GIS software package, which one are you using:

Email/Mail Address

Email Notifications of sample processing
PDF report of analysis
Data file

Email/Mail Address

Email Notifications of sample processing
PDF report of analysis
Data file

Email/Mail Address

Email Notifications of sample processing
PDF report of analysis
Data file

Business Description & Additional Notes:

Submission of this information is a formal request to establish an account to do business with A & L Great Lakes Laboratories, Inc. If an account is granted, I accept payment terms of Net 30 days. Additionally, if an account is delinquent, interest will be charged on past due balances, at a rate of 1½ percent per month.

Name of Individual Submitting

Date

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A&L Great Lakes Laboratories, Inc. is an independently owned and operated agricultural testing laboratory located in Fort Wayne, Indiana. Our intent is to deliver fast, accurate analyses that you can trust to make your most important decisions.

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Lab Account

Contact Information

Billing Information

Primary Industry

Report Contacts

(People who should receive reports)

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