If you are having trouble submitting this form please contact us for an alternative format. Current Start Details of samples Complete Company name Company name to appear on report (if different from above company name) Address line 1 Address line 2 City/town State/province Country Postcode Contact name Email address (this is for your report, invoice and reference number) Phone Have you used any of our Ultraviolet Radiation Services before? Yes No I hereby authorise the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) to conduct testing of the samples described below. I have read and agree to abide by the Terms & Conditions for Service and Conditions for Test Samples. I agree Leave this field blank