SAMPLE CARD

Contract ID :
Project Name :

Kind of Materials :
Sample Identification :
Quantity Represented :
Sampled At :
(Give accurate location as posible)

Original Source :
Owner / Supplier :
Sampled / Casted by :
(Name of authorized representative) (Signature)

(Designation) (Office) (Date)

Proposed Used :
Test Desired :
Governing Specification:
Shippied by :
(Name & Designation) (Office) (Date)

Send Result to :

(Mailing Address)

Remarks :
Bill Charge to :
(Contractor) (Address)

Submitted by :
(Name of Authorized Representative) (Signature)

(Designation) (Office) (Date)

Received By : Laboratory No. :

Date :