Client Name

Prepared by (if requested by representative)

Client Phone

Client Email

Agent's Name (if applicable)

Agent's Phone (if applicable)

Agent's Email (if applicable)

Purpose of Testing Purpose of Testing FHA, VA, USDA Loan Private Well Testing Construction Line Clearance Well Clearance Other

If other, please describe

What is Your Closing Date?

I confirmed with my lender what their sampling requirements are for my loan. I confirmed with my lender what their sampling requirements are for my loan. Yes No

Address for Sample Collection

Water Testing Requested, select all that apply. Water Testing Requested, select all that apply. I need sample collection (prices quoted by phone / email) Total Coliform Testing, $25, 3-5 day turn around time Nitrate Testing, $35, 3-5 day turn around time Nitrite Testing, $35, 3-5 day turn around time Lead Testing, standard, $35, 14 day turn around time Lead Testing, rush, $70, 3-5 day turn around time Lead Testing, 24hr, $95, 36-48 hour turn around time Other:

If other, please describe:

Report Disclaimer: Lead samples will be sent to a contract lab for analysis, but we will provide the final report. Ultimately, lead testing is out of our ability to control. Report Disclaimer: Lead samples will be sent to a contract lab for analysis, but we will provide the final report. Ultimately, lead testing is out of our ability to control. I Accept

Site Information: Site Information: Occupied Vacant, < 30 days Vacant, > 30 days Dogs on site - Please secure pet in crate or room with solid door Water Softener or treatment system on site

Lock box code (if applicable)

What is your preferred collection date, subject to availabilty

Please add any additional information here.