Specimen Description
Test Per 16 CFR 1633
For TSS Use Only

Test No.

 _________

Lab No.

 _________

Please complete one form for every specimen set presented

Today's Date:. _________________     Please type or print clearly

Please print this form from your browser, fill it out, then fax to (616)532-0447, or send with sample
Company Name & Address: 
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Contact Person:
_____________________________________
Title__________________________________
Phone:(___)________________Ext:__________ 
E-Mail:________________________________

Bill To Address: Same as above
_____________________________________
_____________________________________
_____________________________________
_____________________________________

Mailing Address for Report: 
_____________________________________
_____________________________________
_____________________________________
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Video Required:    No Yes 

Return Sample:     No Yes 

Purchase Order #:
 Who will Witness?
    
Specimen Information Required
Product Name/Description:
 Prototype ID:
Caution: The performance of the submitted sample is not necessarily an accurate indication of the performance in a real-life fire situation

TouchStone Systems & Services, Inc.
1817 Porter Street S.W., Wyoming, MI  49519
Phone: (616)532-0060    Toll Free: (888)532-0060
Fax: (616)532-0447     E-Mail: touchsto@iserv.net