Integrity Testing Sample Submission Sheet

Below are fields that are necessary to write the report(s) for your sample(s). Please fill out all fields to the fullest extent. If a field does not apply to your test sample, please enter “N/A” and we will remove that field from the report.

Company Name(Required)

Quote Number

Number of Samples(Required)

Unit 1

Unit 1: Sample Identification(Required)

How the product will be identified in the report

Unit 1: Product Description(Required)

Describe product and its use

Unit 1: Manufacturer(Required)

Unit 1: Associated ID Numbers:

Unit 1: Reference Number(s)

Unit 1: Model Number(s)

Unit 1: Serial Number(s)

Unit 1: Part Number(s)

Unit 1: Other (Please Specify)

Unit 1: Dimensions(Required)

Length (in.)

Width (in.)

Height (in.)

Unit 1: Weight(Required)

Specify: lbs., kgs, or other

Unit 1: Test(s) Required:(Required)

Unit 1: Accelerated Aging Details:

Target shelf life Ambient Shelf Temp. (typically 23C) Acc. Aging Temp. (typically 55C) Q10 Factor (typically 2.0)

Unit 1: Seal Strength Pull Orientation

List How many pulls per sample and location(s) on sample to be used (ex: 1 pull opposite end of pouch’s chevron per sample)

Unit 1: Leak Testing (D3078 – D4991)

List target pressure

Unit 1: Other (Please Specify)

Unit 1: Test Sequence (if applicable)

List all testing requested in the order to be completed

Unit 1: Additional Comments

Unit 2

Unit 2: Sample Identification(Required)

How the product will be identified in the report

Unit 2: Product Description(Required)

Describe product and its use

Unit 2: Manufacturer(Required)

Unit 2: Associated ID Numbers:

Unit 2: Reference Number(s)

Unit 2: Model Number(s)

Unit 2: Serial Number(s)

Unit 2: Part Number(s)

Unit 2: Other (Please Specify)

Unit 2: Dimensions(Required)

Length (in.)

Width (in.)

Height (in.)

Unit 2: Weight(Required)

Specify: lbs., kgs, or other

Unit 2: Test(s) Required:(Required)

Unit 2: Accelerated Aging Details:

Target shelf life Ambient Shelf Temp. (typically 23C) Acc. Aging Temp. (typically 55C) Q10 Factor (typically 2.0)

Unit 2: Seal Strength Pull Orientation

List How many pulls per sample and location(s) on sample to be used (ex: 1 pull opposite end of pouch’s chevron per sample)

Unit 2: Leak Testing (D3078 – D4991)

List target pressure

Unit 2: Other (Please Specify)

Unit 2: Test Sequence (if applicable)

List all testing requested in the order to be completed

Unit 2: Additional Comments

Unit 3

Unit 3: Sample Identification(Required)

How the product will be identified in the report

Unit 3: Product Description(Required)

Describe product and its use

Unit 3: Manufacturer(Required)

Unit 3: Associated ID Numbers:

Unit 3: Reference Number(s)

Unit 3: Model Number(s)

Unit 3: Serial Number(s)

Unit 3: Part Number(s)

Unit 3: Other (Please Specify)

Unit 3: Dimensions(Required)

Length (in.)

Width (in.)

Height (in.)

Unit 3: Weight(Required)

Specify: lbs., kgs, or other

Unit 3: Test(s) Required:(Required)

Unit 3: Accelerated Aging Details:

Target shelf life Ambient Shelf Temp. (typically 23C) Acc. Aging Temp. (typically 55C) Q10 Factor (typically 2.0)

Unit 3: Seal Strength Pull Orientation

List How many pulls per sample and location(s) on sample to be used (ex: 1 pull opposite end of pouch’s chevron per sample)

Unit 3: Leak Testing (D3078 – D4991)

List target pressure

Unit 3: Other (Please Specify)

Unit 3: Test Sequence (if applicable)

List all testing requested in the order to be completed

Unit 3: Additional Comments

Unit 4

Unit 4: Sample Identification(Required)

How the product will be identified in the report

Unit 4: Product Description(Required)

Describe product and its use

Unit 4: Manufacturer(Required)

Unit 4: Associated ID Numbers:

Unit 4: Reference Number(s)

Unit 4: Model Number(s)

Unit 4: Serial Number(s)

Unit 4: Part Number(s)

Unit 4: Other (Please Specify)

Unit 4: Dimensions(Required)

Length (in.)

Width (in.)

Height (in.)

Unit 4: Weight(Required)

Specify: lbs., kgs, or other

Unit 4: Test(s) Required:(Required)

Unit 4: Accelerated Aging Details:

Target shelf life Ambient Shelf Temp. (typically 23C) Acc. Aging Temp. (typically 55C) Q10 Factor (typically 2.0)

Unit 4: Seal Strength Pull Orientation

List How many pulls per sample and location(s) on sample to be used (ex: 1 pull opposite end of pouch’s chevron per sample)

Unit 4: Leak Testing (D3078 – D4991)

List target pressure

Unit 4: Other (Please Specify)

Unit 4: Test Sequence (if applicable)

List all testing requested in the order to be completed

Unit 4: Additional Comments

Unit 5

Unit 5: Sample Identification(Required)

How the product will be identified in the report

Unit 5: Product Description(Required)

Describe product and its use

Unit 5: Manufacturer(Required)

Manufacturers of any of the sample components that need to be listed in report

Unit 5: Associated ID Numbers:

Unit 5: Reference Number(s)

Unit 5: Model Number(s)

Unit 5: Serial Number(s)

Unit 5: Part Number(s)

Unit 5: Other (Please Specify)

Unit 5: Dimensions(Required)

Length (in.)

Width (in.)

Height (in.)

Unit 5: Weight(Required)

Specify: lbs., kgs, or other

Unit 5: Test(s) Required:(Required)

Unit 5: Accelerated Aging Details:

Target shelf life Ambient Shelf Temp. (typically 23C) Acc. Aging Temp. (typically 55C) Q10 Factor (typically 2.0)

Unit 5: Seal Strength Pull Orientation

List How many pulls per sample and location(s) on sample to be used (ex: 1 pull opposite end of pouch’s chevron per sample)

Unit 5: Leak Testing (D3078 – D4991)

List target pressure

Unit 5: Other (Please Specify)

Unit 5: Test Sequence (if applicable)

List all testing requested in the order to be completed

Unit 5: Additional Comments

Unit 6

Unit 6: Sample Identification(Required)

How the product will be identified in the report

Unit 6: Product Description(Required)

Describe product and its use

Unit 6: Manufacturer(Required)

Unit 6: Associated ID Numbers:

Unit 6: Reference Number(s)

Unit 6: Model Number(s)

Unit 6: Serial Number(s)

Unit 6: Part Number(s)

Unit 6: Other (Please Specify)

Unit 6: Dimensions(Required)

Length (in.)

Width (in.)

Height (in.)

Unit 6: Weight(Required)

Specify: lbs., kgs, or other

Unit 6: Test(s) Required:(Required)

Unit 6: Accelerated Aging Details:

Target shelf life Ambient Shelf Temp. (typically 23C) Acc. Aging Temp. (typically 55C) Q10 Factor (typically 2.0)

Unit 6: Seal Strength Pull Orientation

List How many pulls per sample and location(s) on sample to be used (ex: 1 pull opposite end of pouch’s chevron per sample)

Unit 6: Leak Testing (D3078 – D4991)

List target pressure

Unit 6: Other (Please Specify)

Unit 6: Test Sequence (if applicable)

List all testing requested in the order to be completed

Unit 6: Additional Comments

Unit 7

Unit 7: Sample Identification(Required)

How the product will be identified in the report

Unit 7: Product Description(Required)

Describe product and its use

Unit 7: Manufacturer(Required)

Unit 7: Associated ID Numbers:

Unit 7: Reference Number(s)

Unit 7: Model Number(s)

Unit 7: Serial Number(s)

Unit 7: Part Number(s)

Unit 7: Other (Please Specify)

Unit 7: Dimensions(Required)

Length (in.)

Width (in.)

Height (in.)

Unit 7: Weight(Required)

Specify: lbs., kgs, or other

Unit 7: Test(s) Required:(Required)

Unit 7: Accelerated Aging Details:

Target shelf life Ambient Shelf Temp. (typically 23C) Acc. Aging Temp. (typically 55C) Q10 Factor (typically 2.0)

Unit 7: Seal Strength Pull Orientation

List How many pulls per sample and location(s) on sample to be used (ex: 1 pull opposite end of pouch’s chevron per sample)

Unit 7: Leak Testing (D3078 – D4991)

List target pressure

Unit 7: Other (Please Specify)

Unit 7: Test Sequence (if applicable)

List all testing requested in the order to be completed

Unit 7: Additional Comments

Unit 8

Unit 8: Sample Identification(Required)

How the product will be identified in the report

Unit 8: Product Description(Required)

Describe product and its use

Unit 8: Manufacturer(Required)

Unit 8: Associated ID Numbers:

Unit 8: Reference Number(s)

Unit 8: Model Number(s)

Unit 8: Serial Number(s)

Unit 8: Part Number(s)

Unit 8: Other (Please Specify)

Unit 8: Dimensions(Required)

Length (in.)

Width (in.)

Height (in.)

Unit 8: Weight(Required)

Specify: lbs., kgs, or other

Unit 8: Test(s) Required:(Required)

Unit 8: Accelerated Aging Details:

Target shelf life Ambient Shelf Temp. (typically 23C) Acc. Aging Temp. (typically 55C) Q10 Factor (typically 2.0)

Unit 8: Seal Strength Pull Orientation

List How many pulls per sample and location(s) on sample to be used (ex: 1 pull opposite end of pouch’s chevron per sample)

Unit 8: Leak Testing (D3078 – D4991)

List target pressure

Unit 8: Other (Please Specify)

Unit 8: Test Sequence (if applicable)

List all testing requested in the order to be completed

Unit 8: Additional Comments

Unit 9

Unit 9: Sample Identification(Required)

How the product will be identified in the report

Unit 9: Product Description(Required)

Describe product and its use

Unit 9: Manufacturer(Required)

Unit 9: Associated ID Numbers:

Unit 9: Reference Number(s)

Unit 9: Model Number(s)

Unit 9: Serial Number(s)

Unit 9: Part Number(s)

Unit 9: Other (Please Specify)

Unit 9: Dimensions(Required)

Length (in.)

Width (in.)

Height (in.)

Unit 9: Weight(Required)

Specify: lbs., kgs, or other

Unit 9: Test(s) Required:(Required)

Unit 9: Accelerated Aging Details:

Target shelf life Ambient Shelf Temp. (typically 23C) Acc. Aging Temp. (typically 55C) Q10 Factor (typically 2.0)

Unit 9: Seal Strength Pull Orientation

List How many pulls per sample and location(s) on sample to be used (ex: 1 pull opposite end of pouch’s chevron per sample)

Unit 9: Leak Testing (D3078 – D4991)

List target pressure

Unit 9: Other (Please Specify)

Unit 9: Test Sequence (if applicable)

List all testing requested in the order to be completed

Unit 9: Additional Comments

Unit 10

Unit 10: Sample Identification(Required)

How the product will be identified in the report

Unit 10: Product Description(Required)

Describe product and its use

Unit 10: Manufacturer(Required)

Unit 10: Associated ID Numbers:

Unit 10: Reference Number(s)

Unit 10: Model Number(s)

Unit 10: Serial Number(s)

Unit 10: Part Number(s)

Unit 10: Other (Please Specify)

Unit 10: Dimensions(Required)

Length (in.)

Width (in.)

Height (in.)

Unit 10: Weight(Required)

Specify: lbs., kgs, or other

Unit 10: Test(s) Required:(Required)

Unit 10: Accelerated Aging Details:

Target shelf life Ambient Shelf Temp. (typically 23C) Acc. Aging Temp. (typically 55C) Q10 Factor (typically 2.0)

Unit 10: Seal Strength Pull Orientation

List How many pulls per sample and location(s) on sample to be used (ex: 1 pull opposite end of pouch’s chevron per sample)

Unit 10: Leak Testing (D3078 – D4991)

List target pressure

Unit 10: Other (Please Specify)

Unit 10: Test Sequence (if applicable)

List all testing requested in the order to be completed

Unit 10: Additional Comments

Package Testing Types

Package Testing Capabilities

Cold Chain

Aging

Industries

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