SPSB 153, Box 2108. Jack Rabbit Lane. Brookings, SD 57007-1090. Phone: (605)688-5545 Fax: (605)688-4024. E-mail: sdsu.pd
Sample Submission Form Plant Diagnostic Clinic SPSB 153, Box 2108 Jack Rabbit Lane Brookings, SD 57007-1090 Phone: (605)688-5545 Fax: (605)688-4024 E-mail:
[email protected]
For Lab Use Only Rec’d:_________________
Condition on Arrival Excellent Fair
Good Poor
Amt:__________ Date:__________
Called (Date & Initials)
CLIENT
SUBMITTER/Billing Address
Check if Client is to be billed instead of submitter Name:_________________________________________ Name:_________________________________________ Business Name:_________________________________ Business Name:_________________________________ Address:_______________________________________ Address:_______________________________________ City/State/Zip:__________________________________ City/State/Zip:__________________________________ Phone:__________________Cell:__________________ Phone:___________________Cell:__________________ E-mail:________________________________________ E-mail:_________________________________________
Sample Fees: Will be billed to Submitter unless otherwise notified. Basic diagnosis is $15.00 (only in state fee). You will be notified if a more advance analysis is needed. Make checks payable to: SDSU Plant Diagnostic Clinic Date Collected:______________________________Crop/ Plant or Other:______________________________ County Collected:______________________________Variety/Cultivar:_______________________________
Chemical History:
Chemical Name
Application Date
Rate
Previous Year
Fertilizer:_______________________________________________________________________________________ Herbicide:_______________________________________________________________________________ Insecticide:______________________________________________________________________________ Fungicide:_______________________________________________________________________________
When did you first notice the symptoms/problems? Please describe problem and culture practices in detail (water, sun, plant age, etc.). Attach photos if possible (Please use reverse side for more space).
