www.warrenlab.com

NUTRITIONAL LABELING
ANALYSIS REQUEST FORM

kates@warrenlab.com

Warren Analytical Laboratory
650 "O" Street
Greeley, CO  80631

970-475-0252
FAX  970-351-6648
800-945-6669

Lab Use Only:
Work Order #

Client I.D.#

Date:

1

Reporting Information

2

Billing Information

Company:

Company:

Contact Person:

Contact Person:

Address:

Address:

Phone:

P.O.#

Fax:

Account #

Email:

Submitted by:

3

Results Reporting (check box)

4

Turn Around Time (check box)

Phone Results:

Yes

No

Standard

Fax Results:($1.00 fee per fax connection)

Yes

No

Priority (100% Surcharge. Please Call.)

Email Results:

Yes

No

5

Sample Description:

6

Serving Information:

Household Measurement (e.g. cup, slice, piece) -

Equivalent Metric Quantity (g, oz, etc.) -

Servings Per Container -

7

Special Instructions:

8

Required Analysis for
Nutritional Labeling

Check
Box

Expected
Range

Optional Analysis for
Nutritional Labeling

Check
Box

Expected
Range

Total Fat

Thiamin (B₁)

Moisture

Riboflavin (B₂)

Protein

Potassium

Ash

Complex Carbohydrates

Carbohydrates

Sugar Alcohol

Sugars

Total Unsaturated Fat

Calories

Monounsaturated Fat

Calcium

Polyunsaturated Fat

Iron

Sodium

Vitamin A

Vitamin C

Saturated Fat

Cholesterol

Total Dietary Fiber

© 2001 Warren Analytical Laboratory

CBM-163

 6/02