SAMPLING KIT REQUEST FORM

Customer Name:

Ship Name:

Port of call:

ETA/ETD [Note 1]: (m/d/yyyy format)

Type of kits:	Quantity [Note 2]:

2 boxes
Fuel	Lube

DELIVER TO

Company Name:
Address [Note 3]:
City, State:
Zip (Postal Code):
Country:
Telephone:
Fax:
Email:

Notes:

This request must be sent to us at least 5 working days prior to ETA of the vessel for delivery.

One box contains 6 sampling kits (6 bunkering operations).

Please do not provide P.O. box address. Courier companies do not accept P.O. Box addresses. It should be street address.

VISWA LAB CORPORATION

8423 Almeda Road, Suite ‘S’

Houston, Texas 77054, USA

Issued: May-2003

Tel:	USA (713) 842-1985
Fax:	USA (713) 842-1981
Email:	customerhelp@viswalab.com
Web:	http://www.viswalab.com

KIT REQUEST FORM

RAMAN

2003-07-18

Viswa Lab Corp.