Soybean Cyst Nematode Sample Form

	Grower Information


	Name:_________________________________ Address:_______________________________ ________________________________ ________________________________ Phone:_______________ Fax:______________ E-mail:__________________________		Copy results to:__________________________ Address:_______________________________ ________________________________ ________________________________ Phone:_______________ Fax:______________ E-mail:__________________________

Name:_________________________________

Address:_______________________________

________________________________

Phone:_______________ Fax:______________

E-mail:__________________________

Copy results to:__________________________

Address:_______________________________

________________________________

Phone:_______________ Fax:______________

E-mail:__________________________

	Who is to be billed for sample processing ? ________________________________

	Crop Information


	County:_______________________________ Township:_____________________________ Field Identification:_________________________ Number of Acres:______________________		Current Crop:_________________ Variety:______________________ Previous Cops: Year:______ Crop:__________ Year:______ Crop:__________

County:_______________________________

Township:_____________________________

Field Identification:_________________________

Number of Acres:______________________

Current Crop:_________________

Variety:______________________

Previous Cops:

Year:______ Crop:__________

The CWEPPDC charges a fee for sample processing of $15 per sample per shipment. You will receive a bill with your results.

Complete one form for each sample submitted. DO NOTsend form inside bag with soil.

Lab Use Only

Soybean Cyst Nematode:

_____eggs/200 cc of soil

_____juveniles/200 cc of soil

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