Capitol Vial Inc. : Sample Request Form

Off-Site Drugs
of Abuse Testing

· Single Specimen
Collection Kit

· Split Specimen
Collection Kit (SAMHSA)

  · Single Specimen
    Collection Kit with
    90 ml Flip-Top
    Vial in Bag

  · Dual Pocket
    Biohazard Bags for
    Specimen Transport

· 90ml Wide-Mouth
Flip-Top Vial

· 5-up & 10up Wide-Mouth
Flip-Top Vial

  · Collection Cups for
    Traditional &
    On-Site Testing

· Temperature
Indicator Strips

· Drugs of Abuse
Testing Supplies

On-Site Drugs
of Abuse Testing

· Snap on Slot Lid
Container Caps

· Confirmation Test
Transport Vial

  · 90ml Wide-Mouth
    Universal On-Site
    Collection and
    Transport Container

  · Dairy Industry
    Containers for
    Milk Sampling

  · Veterinary Specimen
    Collection &
    Transport Vials

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Request Date:

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Contact Name:*

Phone Number:*

Fax Number:

E-mail Address:*

Please have a sales representative call me.

Please email a quotation on sample items requested.
(provide annual volume below)

Company/Institution:

Address 1:

Address 2:

City:

State/Province:

Postal Code:

Country:

Primary Field of Practice:

Application for Containers:

Sample Request Information:


Part Number	Description	Quantity	Annual Volume

Additional Comments

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