CAES: 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, P. O. Box 1106
New Haven, CT 06504-1106


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:

Name: ______________________________________ Date: _______________________
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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Content Last Modified on 4/10/2007 4:19:32 PM