/ AGLAEAssociation
427 rue des Bourreliers
Parc des Pyramides
59320 Hallennes lez Haubourdin - France
 +33 (0)3 20 16 91 40


application and registration form - AGLAE’s 2017 scheme

Please complete this form by computer

Presentation of your laboratory

Name of your company:
Name of your laboratory:
Limited to 35 characters / Type: Private
Public
Semi-public

Activity sector:

Medical biology laboratory / Hospital
Analyses provider
Environment
Food
Other analyses, please specify: / Industrial
Environment
Food
Other analyses, please specify:
Other, please specify:

Date the laboratory was created:

Number of employees carrying out the analyses:

Is your lab accredited:

ISO/CEI 17025? Yes No In progress

If yes, for which scope?

ISO/CEI 15189? Yes No In progress

Is your laboratory ‘officially approved’ by a third party (government approval, certification….)? Yes No

If yes, which one?

If you are neither accredited nor certified, how do you monitor (in a few words) the analytical performance of your laboratory?

Contact details of your laboratory

Delivery address for the test materials:

ATTENTION: we do not wish deliveries in a P.O.box. This address should be the location of your laboratory.

/ Address:
Address line 2:
Postalcode -Town:
Country:
Tel:
@:

Limited to 35 characters per data field

If the invoice address is different, please specify it underneath:

/ Address:
Address line 2:
P.O. box:
Postal code - Town:
Country:

Person in charge of "accounts payable":

Mr Mrs MissName:

Tel: @:

European Union VAT number:

Necessary for laboratories within the European Union. Without it, the French VAT will apply.

Other information

How did you hear about AGLAE?

Through web searches / Through third parties: ISO, accreditation body
Through events: workshop, show / By another laboratory
Through EPTIS / Other, please specify:

List of programmes requested

⇨Please tick the programmes and tests you are interested in.

Note that the parameters and matrices may be different from one round to the following one. Check their description in the catalogue.

A quoteshall be sent upon receipt of this completed document.

The number of tests left and the transport fees will be taken into account.

Medical Biology / 1st 2nd 3rd 4th / Waters for medical use / 1st 2nd
80Cyto-bacteriology of urines / 82Endotoxins in waters intended for medical use
84 Coproculture / 83A Microbiology in waters similar to dialysis waters
85Blood culture / 83BMicrobiology in waters similar to endoscope waters
87Cytobacteriology of the cerebrospinal fluid / 86 Indicator germs in bacteriologically controlled waters
88 Cytobacteriology of sputum
Microbiology in waters / 1st 2nd 3rd 4th / Biology and ecotoxicology / 1st 2nd
11Escherichia coli and intestinal enterococci by MPN method / 12 Hydrobiology
30 Microbiology in clean waters / 13 Ecotoxicology
31 Pseudomonas aeruginosa and pathogenic staphylococci in clean waters / 16 Biological Diatom Index
32 Legionella and Legionella pneumophila in clean waters by culture / 34 Protozoans in clean waters
33Legionella and Legionella pneumophila in waste waters by culture
35 Legionella and Legionella pneumophila in clean waters by PCR
36 Legionella and Legionella pneumophila in waste waters by PCR
37 Salmonella in clean waters
38Yeast in clean waters
Base parameters and indicators in waters / 1st 2nd / Metals in waters / 1st 2nd 3rd
Clean waters / 3A Metals in clean waters
1A Chemical analyses in clean waters / 3B Metals in waste waters
1Ab Chemical analyses in clean waters at low concentration levels / 3C Metals in flat natural mineral waters (bottled)
1B Indicators in natural waters / 3D Cr6+in natural and waste waters
1C Chlorophyll a and pheopigments index in natural waters
1D Disinfection products in clean waters / Indexes in waters / 1st 2nd 3rd 4th
1E Dissolved oxygen in clean waters / 5AGlobal indexes in natural waters
1G Dry residue in clean waters / 5BGlobal indexes in waste waters
50 Perchlorates and disinfection by-products in clean waters / 5C Total hydrocarbons index in natural and waste waters
50ADisinfection by-products in swimming pool waters / 5D Volatile hydrocarbons index in natural and waste waters
91 Odour and flavour in clean waters
Waste waters / Chemistry in solid matrices / 1st 2nd 3rd 4th
2A Chemical analyses in waste waters / 9 Chemical analyses and metals in sediments
2B Indicators in waste waters / 10Organic micropollutants in sediments
2C Indicators in waste waters at low concentration levels / 40Chemical analyses and metals in recoverable sewage sludges
Saline waters / 41Organic micropollutants in recoverable sewage sludges
6 Chemical analyses in saline waters / 43Chemical analyses and metals in contaminated sites and soils
Carbogaseous waters / 44Organic micropollutants in contaminated sites and soils
90 Chemical analysis in carbogaseous waters / 51Chemical analyses and metals in waste (leaching)
Organic pollutants in clean or natural waters / 1st 2nd / Organic pollutants in waste waters / 1st 2nd
4C Volatile organohalogens and benzene derivatives in clean waters / 4E Volatile organohalogens and benzene derivatives in waste waters
4Cb Volatile organohalogens and benzene derivatives in clean waters at low concentration levels / 4Eb Volatile organohalogens and benzene derivatives in waste waters at low concentration levels
20A Other Priority substances - Chlorophenols in natural waters / 20B Other Priority substances - Chlorophenols in waste waters
21A Other Priority substances - Alkylphenols in natural waters / 21B Other Priority substances - Alkylphenols in waste waters
22A Other Priority substances - Chloroanilines in natural waters / 22B Other Priority substances - Chloroanilines in waste waters
23A Other Priority substances - Organotin compounds in natural waters / 23B Other Priority substances - Organo-tin compounds in waste waters
24A Other Priority substances - Brominated Diphenyl Ethers in natural waters / 24B Other priority substances - Brominated Diphenyl Ethers in waste waters
25A Other Priority substances - Biphenyl in natural waters / 25B Other Priority substances - Biphenyl in waste waters
26A Other Priority substances - Phthalates in natural waters / 26B Other Priority Substances – Phthalates in waste waters
27A Other Priority substances - C10-C13 chloroalkanes (SCCPs) in natural waters / 27B Other priority substances - C10-C13 chloroalkanes (SCCPs) in waste waters
28A Other Priority substances - Chloroacetic acid in natural waters / 28B Other Priority Substances – Chloroacetic acid in waste waters
29A Other Priority substances - Epichlorohydrin in natural waters / 29B Other Priority substances - Epichlorohydrin in waste waters
52 AOX in clean waters and waste waters / 52AOX in clean and waste waters
54 Toxins of cyanobacteria in natural waters / 71 PAHs and PCBs in waste waters
55 Glyphosate, AMPA and Aminotriazole in clean waters / 72 Pesticides and degradation residues in waste waters
57 Pharmaceuticals in natural waters / 73 Alkylphenol ethoxylates in waste waters
58 Bisphenol A in natural waters
59 Perfluorinated compounds in natural waters
64PAHs and PCBs in clean waters
65A Pesticides and degradation residues - List 1 - in natural waters
65B Pesticides and degradation residues – List 2 - in natural waters
65C Pesticides and degradation residues - List 3 - in natural waters
65D Pesticides and degradation residues - List 4 - in clean waters
66THMSs in swimming pool waters
67 Acrylamide in natural waters
69 Metabolites of chloroacetamides in natural waters

Completion

Completed on the (date) in (town)

By (name) as (job position)

Please return it completed by email to:

Note: information given in this document shall not be disclosed.

Er-5-05-EN, Application and registration form
Issue No. 00, Revised on: 28/11/16 - PTS: 2017 / Page 1 / 4