Connecticut State The Connecticut Agricultural Experiment Station

Inquiry Office, Sample Submission Form, Windsor

Sample Submission Form: Insects
Valley Laboratory, Windsor

Send sample submission form to:
Inquiry Office
The Connecticut Agricultural Experiment Station
153 Cook Hill Road, P.O. Box 248
Windsor, CT 06095

Date:_____________________
Name: ____________________________________________________________     
Address:___________________________________________________________      
           ___________________________________________________________                 
Phone:_____________________
Fax: _______________________
Email:_____________________

( ) construction contractors
( ) educational institution
( ) financial institutions
( ) food industry
( ) grower/nursery/orchard/farm
( ) health department
( ) home inspector/realtor
( ) homeowner
( ) landscaper/arborist
( ) legal profession
( ) manufacturer
( ) medical/veterinary
( ) municipal/state/federal agency
( ) museum
( ) pest control operator
( ) retail industry
( ) other:__________________________
If you are submitting a sample on behalf of someone else, please fill in details below:
Date:_____________________
Name: ____________________________________________________________     
Address:___________________________________________________________      
           ___________________________________________________________                 
Phone:_____________________
Fax: _______________________
Email:_____________________

SAMPLE FOR:
( ) Identification only
( ) Identification and Control

Source of specimen(s) indoors:

( ) attic ( ) cupboards ( ) pantry
( ) basement ( ) family room ( ) porch
( ) bathroom ( ) furniture ( ) workplace
( ) bedroom ( ) kitchen ( ) other
( ) closets ( ) laundry room

Source of specimen(s) outdoors:

( ) barn ( ) lawn ( ) shed
( ) exterior of house ( ) nursery ( ) shrubs/trees
( ) field ( ) orchard ( ) vegetable garden
( ) flower garden ( ) pathways ( ) vehicle
( ) foundation plants ( ) playground ( ) woods
( ) garage ( ) roof ( ) yard
( ) greenhouse ( ) sandbox ( ) other

Comments:
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