SUPPLY REQUEST FORM

1CONTACT INFORMATION

2ORDER INFORMATION

Requester's Name*
Email*
Company Name*
Company Account #
P.O. Number
Mailing Address*
Street Address Address Line 2 City Province Postal Code
Shipping Address*
Street Address Address Line 2 City Province Postal Code
Shipping Address*
- SAME as my mailing address
- DIFFERENT (please indicate)
Shipping Method*
- We will pickup
- Please send via our courier
- IG Micromed local driver
State desired date and time of pickup:*
Provide your courier name:*
Provide your account number:*
Our Local driver (based on region and availability. A delivery fee will apply. Not available in all regions. Will be confirmed if possible.)

Please indicate the quantity for each item that you require.
(lot number is for internal use)
DE 3M Pathogen Sponges - Lot Number: Quantity
Price: $ 3.50 CAD
Copan Q-Tip Swabs - Lot Number: Quantity
Price: $ 1.45 CAD
Micro Water Sampling Bottles (250ml) Quantity
Price: $ 1.65 CAD
To be used for sampling drinking water. Contains sodium thiosulphate as dechlorinating agent.
Micro Water Sampling Bottles (500ml) Quantity
Price: $ 2.70 CAD
For sampling drinking water. Contain sodium thiosulphate as dechlorinating agent.
Peptone Buffer Sponges - Lot Number: Quantity
Price: $ 3.50 CAD
General Potability Water Sampling Kit Quantity
Price: $ 2.70 CAD
1 500 ml General Chemistry bottle, 1 metals bottle, 1 cyanide bottle, 1 mercury bottle, 1 250 ml micro bottle.
Settle Plates - Yeast and Mold (PDA) - Lot Number: Quantity
Price: $ 3.50 CAD
The recommended expiry date for settle plates is one week.
Settle Plates - Total Bacteria (SPC) - Lot Number: Quantity
Price: $ 3.50 CAD
The recommended expiry date for settle plates is one week.
Settle Plates - TSA - Lot Number: Quantity
Price: $ 4.50 CAD
The recommended expiry date for settle plates is one week.
Peptone Solution - 400 ml bottles - Lot Number: Quantity
Price: $ 7.50 CAD
Butterfield Solution - 400 ml bottles - Lot Number: Quantity
Price: $ 6.80 CAD
Sterile Sampling Bags - 7” X 12” Quantity
Price: $ 2.70 CAD
Sterile Sampling Bags - 5 1/2 " X 7 " Quantity
Price: $ 2.70 CAD
Chicken Bags - For Poultry Rinse Quantity
Price: $ 2.20 CAD
WLN Media Plates plus Actidone. Lot Number: Quantity
Price: $ 70.00 CAD
WLN Media plus Actidone plates for breweries. Sold in packages of 10 plates.
PDA Plates 150 mm Special Order - Package of 3 Lot Number: Quantity
Price: $ 11.00 CAD
PDA Plates 150 mm Special Order - Package of 3
SPC Plates 150 mm Special Order Package of 3 Lot Number: Quantity
Price: $ 11.00 CAD
SPC Plates 150 mm Special Order Package of 3
Rodac Contact Plates (package of 10) Quantity
Price: $ 20.85 CAD
Rodac Contact Plates (package of 10)
THM Sampling Bottles - package of 2 Quantity
Price: $ 2.50 CAD
THM Sampling Bottles - package of 2
VOC Sampling Bottles Quantity
Price: $ 2.50 CAD
Metals in Water Sampling Bottle Quantity
Price: $ 2.25 CAD
Metals in Water Sampling Bottles including Mercury Bottle.
Oil and Grease Glass Water Sampling Bottle Quantity
Price: $ 2.25 CAD
Glass bottles with additive for Oil and Grease Analysis Sampling.
Allergen Swabs Quantity
Price: $ 1.65 CAD
Dry Swabs for sampling surfaces for allergens
Special Instructions / Information:
TOTAL COST
$ 0.00 CAD

I.G. MicroMed Environmental Inc.

SUPPLY REQUEST FORM

Please indicate the quantity for each item that you require.