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2. Collector/Sample Information (results are returned to this address)
4. Date and Time Collected*
   Date and Time Collected

   Date and Time Collected
5. Bottle Number*
7. Collector First Name*
8. Collector Last Name*
10. Email Address*
11. Phone Number*
    Include Area Code
13. Collector's Location Street Address*
14. County*
16. City*
17. State*
18. Zip Code*
20. Owner Information (if different from collector information)
22. Is the owner contact information different from the above?*

    1. Yes
    2. No
24. Owner First Name
25. Owner Last Name
27. Email Address
28. Phone Number

    Include Area Code

30. Owner Street Address
32. City
33. State
34. Zip Code
36. Additional Information
38. Bacteria Test Types
    There is a $13 fee for the bacteria test.
40. Bacteria Test
    Bacteria Test
41. Price
42. Quantity
43. Shipping Cost
45. Taxable
47. Location

    1. Private Home

    1. Dairy

    1. Other
48. Other Location
50. Supply Type*

    1. Non-Community Public
    2. Community Public

    1. Private Well - Single Family
    2. Private Well - Multi Home
51. Sewage Disposal*

    1. City-Sewer

    1. On-Site
53. Construction Type*

    1. Drilled Well

    1. Other
54. Other Construction Type
Leave This Blank:


55. Calculate Totals Proceed to Checkout

* indicates a required field