Insect Information Office, Sample Submission Form, New Haven
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:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________