Romer Labs Inc. 1301 Stylemaster Drive Union, MO 63084-1156, USA Tel: +1 636 583 8600 Fax: +1 636 583 2340 Email: labUSA@romerlabs.com Sample Submission Form – Mycotoxins CONTACT INFORMATION Company Name: Site Address: Invoicing Address: (if different from site address) Contact Name(s): Accounts Payable Contact: Email: Tel/Fax: Tel/Fax: PO# Toxin/Combination Analyses indicate technology: HPLC/TLC Single Toxin Analysis - check 1 of the following toxins: Aflatoxin B1/B2/G1/G2 Cyclopiazonic Acid Diacetoxyscripenol (DAS) HT2 Toxin Nivalenol Sterigmatocystin Aflatoxin M1 Deoxynivalenol (DON) (Vomitoxin) Fumonisin B1/B2/B3 Moniliformin Ochratoxin A T2 Toxin LC-MS/MS Citrinin AcetylDON Fusarenon-X Neosolaniol Patulin Zearalenone Mycotoxin Screen (Aflatoxin, DON, Fumonisin, Zearalenone, Ochratoxin A, Citrinin, Trichothecenes A & B) Three Toxin Screen - check any 3 of the following toxins Aflatoxin DON Zearalenone Ochratoxin A T2 Toxin Four Toxin Screen - check any 4 of the following toxins: DON Fumonisin Zearalenone Ochratoxin A T2 Toxin Five Toxin Screen - check any 5 of the following toxins: DON Fumonisin Zearalenone Ochratoxin A T2 Toxin Aflatoxin Aflatoxin Trichothecenes Screen (Type A & Type B) Type A Trichothecenes (T2 Toxin, HT2 Toxin, DAS, Neosolaniol) Type B Trichothecenes (DON, AcetylDON, Fusarenon-X, Nivalenol) Toxin Analyses by ELISA Aflatoxin Deoxynivalenol (DON) (Vomitoxin) Fumonisin US Lab Submission Form, v.4.0 April 2013 Fumonisin T2 Toxin Ochratoxin A Zearalenone Sample ID Commodity DateSignature Turn Around Times* same day 1 day 3 day 5 day same day 1 day 3 day 5 day same day 1 day 3 day 5 day same day 1 day 3 day 5 day same day 1 day 3 day 5 day same day 1 day 3 day 5 day *ELISA Testing only available with standard 5 day Romer Labs Inc. 1301 Stylemaster Drive Union, MO 63084-1156, USA Tel: +1 636 583 8600 Fax: +1 636 583 2340 Email: labUSA@romerlabs.com Sample Submission Form – Additional Tests CONTACT INFORMATION Company Name: Site Address: Invoicing Address: (if different from site address) Contact Name(s): Accounts Payable Contact: Email: Tel/Fax: Tel/Fax: PO# Other Single Item Analyses Melamine Ergot Alkaloides LC-MS/MS Melamine Grain Grade L C-MS/MS Melamine & Related Compounds Mold Yeast Count (Ammeline, Ammelide, & Cyanuric Acid) Mold Yeast Count & Identification Water Activity Protein Mold Yeast Count Urease Activity Drug Residues ELISA Chloramphenicol Nitrofurans (AMOZ) Nitrofurans (AOZ) GMO Analyses CHC Pesticides & PCB Screen Dioxins (CEF) Organo-Phosphate Pesticide Screen Only (OP) indicate technology: Bt-Cry1F, Herculex Bt-Cry34Ab1, Herculex® Rootworm Bt-Cry9C, StarLink® PAT, Liberty Link® Bt-Cry1Ab, YieldGard® Bt-Cry1Ab & Bt-Cry3Bb1, YieldGard® Plus Bt-Cry3Bb1, YieldGard® Rootworm ® Sample ID US Lab Submission Form, v.4.0 April 2013 Pesticides/PCBS & Other Residues PCR quantitative LFD (Lateral Flow Device) CP4 EPSPS, RoundupReady Bt-Cry1Ac, BollGard® I Bt-Cry2Ac, BollGard® II PMI, Positech® Vip3A, VipTera®, VipCot® EPSPS (GA12), Roundup Ready® ® Commodity DateSignature * Please email or call for more specific turn around time information for your requested analyses. Turn Around Times 1 – 2* weeks dependent upon analyses requested 1 – 2* weeks dependent upon analyses requested 1 – 2* weeks dependent upon analyses requested 1 – 2* weeks dependent upon analyses requested 1 – 2* weeks dependent upon analyses requested 1 – 2* weeks dependent upon analyses requested