Report To Cultivator or Mfg Name Email Address (for results) Address City, State Zip Code Phone Billing Address (if different) Address City, State Zip Code Cultivator or Mfg License or Reg Number Submittal Type Adult Use R&D Medical Personal/Other "Sample Identification (as found on container)" Sample Type* Date Collected Time Collected Sample Size Serving Size* Servings per Package** **For edibles, tinctures, and capsules please include serving size and servings per package information: Analyses Requested Potency*** Homogeneity Terpene Profile Residual Solvents Filth and Foreign Material Microbiological Impurities Water Activity Aflatoxins/Ochratoxins Metals Pesticides Percent Moisture Bacteria Only Yeast & Mold Only Comments, special Instructions, or temperature requirements: *Sample types: (check all that apply) Flower Wet/ Frozen Flower Trim Concentrate CO2/ Solvent Based Concentrate Edible Capsule Tincture 'Other' ***Potency analysis tests (check all that apply) Δ-9-THC THCA CBD CBG CBN CBDA THCV CBDV CBC CBGA exoTHC Δ-8-THC Samples collected by: Date: Electronic Signature Send