PETRO-LUBRICANT TESTING LABORATORIES, INC.
116 Sunset Inn Road, P.O. Box 300, Lafayette NJ 07848 
Phone (973) 579-3448    E-mail petrolube@nac.net    Fax (973) 579-9447
Sample Submission Form
This form MUST accompany all samples. 
In order to avoid delays, please complete ALL sections of this form.
____________________________________________________________________________
Date: 

Contact Name:
 

Phone #:

Fax #:

email: 

 Company Name:
 Address:
 
 
 
 

 
____________________________________________________________________________
Sample Identification:
 
 
 
 

Testing Required:  Please list: Test Method, Time/Temperature, Material Specification, etc.
 
 
 
 
 
 
 
 
 

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[  ]RUSH SECTION
_________________________________________
Petro-Lube Contact                      Date
Note: We do our utmost to meet rush requests but owing to unforeseen circumstances 
we do not guarantee results by a particular date in every instance.		 Rush testing must be pre-approved each time a sample is submitted.
Scheduling of Rush testing will be delayed or may not be available in absence of pre-approval.
Rush testing will incur a minimum 50% surcharge.
___________________________________________________________________________
Method of Payment:   This section MUST be completed.
[  ] Purchase Order No.
#_____________
Net 30 days		 [  ] Visa, MasterCard, American Express 
Card Number:
Expiration Date:		 [  ] Pre-Payment 
Check #:
Amount $