Also: Please Read Lift Tape Instructions
Professional Certification Institute
LIFT TAPE SAMPLING CHAIN OF CUSTODY Form
This lift tape sampling chain of custody is a mold laboratory form that is completed bythe Professional Certification Institute, National Highway, Botong, Lumbangan, Mabinay 6207, Negros Oriental, Philippines. Please print the requested information below with a black ink p the tester (property owner, manager, or agent or employee thereof), who collects the lift tape samples and records the details of each sampling on this form. This form also serves to document both the transfer of custody of the lift tape samplings directly from the tester to the mold lab, and their receipt by the lab.  Please mail (airmail or postal global priority mail) the lift tape samples and this completed Chain of Custody form to en neatly and legibly.

Tester’s name  ________________________________________________________________________________________

Client name ___________________________________________________________________________________________

Client mailing address:_________________________________________________________________________________

_____________________________________________________________________________________________________


Client  Daytime Phone: (________) ___________________________  Client FAX (________)________________________

Client Email:______________________________________________________  Date of sampling____________________

Sampling address______________________________________________________________________________________

______________________________________________________________________________________________________

Type of laboratory mold analysis to be performed:  
 ____ mold verification & quantification (US$149 for each group of 10 lift tape samples).
 ____ mold verification, quantification, & mold species identification (US$224 for each group of 10 lift tape samples).