AOAC LPTP Primary Lab Contact Change Request

All fields must be filled in. Enter NONE, if the information requested does not apply to you.

What Type of Change are you requesting? (select all that apply)*

Primary lab contact name changeLab Name ChangeLab Shipping Address Change

Option 1Option 2Option 3

Your Information (Requester)

Your Name*

First NameLast Name

Your E-mail*

Lab Site & Program Information

Enter the information we have on-file for you

Site ID*

This is your AOAC unique identification number and can be found on invoices, results and logins

Company/Lab Name:*

Program(s) check ALL programs that require this change.*

Lab Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

New Primary Lab Contact Information

NOTE: Please list only one (1) contact person. We may only register one individual as the primary/ship to contact and one e-mail address per lab enrolled in the program. If you require additional personnel in your lab to receive e-mails regarding, invoicing, shipments, and deadlines please contact your IT department to create a group e-mail address.

New Full Name

PrefixFirst NameLast Name

New E-mail:*

New Telephone:

Enter numbers ONLY. Ex: 3019247077

Ext.

Lab Name Change

New Company/Lab Name:*

Lab Shipping Address Change

New Lab Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry