Insect Information Office Sample Submission Form New Haven

Insect Information Office, Sample Submission Form, New Haven

Sample Submission Form
Jenkins Laboratory, New Haven

Send sample submission form to:
The Insect Problems Information Office
The Connecticut Agricultural Experiment Station
123 Huntington Street
New Haven, CT 06511

Name: ______________________________________ Date: _______________________
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:

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:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Connecticut State The Connecticut Agricultural Experiment Station

Insect Information Office, Sample Submission Form, New Haven