Request Form

Customer Type *

Choose Customer TypeCLIA / CAP - Hospitals & Clinical Lab - CLIAUniversities & Research Labs - BASICGMP - ISO 17025 Labs

Product Type *

Choose Product type Pipettes/Syringes/Bottle Dispensers Balances

Service Type *

• On Site
• In House
Select Service Type

Service Date *

Pipettes *

	Operation	Volume Type	Instrument category	Channel Type	Channel Numbers	Images	Quantity

Company / Organisation *

Service Plan *

Choose Service PlanCLIA-1BASICCLIA-2GMP-2CLIA-3GMP-1CLIA-4

• First Name *

• Last Name

• Address1 *

• Address2 *

• State *

• City *

• Zip Code *

• Tel# *

• Email Address

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