……………………………………..
(place and date)
Polish Anti-Doping Laboratory
Księcia Ziemowita Street 53 building 4
03-885 Warsaw
Fax: + 48 22 290 29 04
e-mail: sekretariat@antydopinglab.pl

I hereby request to conduct anti-doping analyses of ……………………… urine and/or blood samples,
							      (planned numer of samples)
collected during:
 ………………………………………………………..…………………………….………….…………. ,
(competition name or its code – TMC)
which is taking place …………….………………………………………….………………..….…….…. .
 (competition date/dates)
The results of analyses should be send to (RMA - Results management authority):
........................................................................................................... ………………………………………
(World or European Sport Federation Name)
Address:	 …………………………………………………….…………………….…………………..
Fax:		 ……………………………………………………………………………………..………..
e-mail:		 ……………………………………………………………………………………..………..
Samples will be taken by (Sample collection authority): 
………………………………………………………………………………………………………………..
(e.g.: POLADA – Polish Anti-Doping Agency)
 TA-Testing Authority:
........................................................................................................... ………………………………………
(World, European, National Federation, Union or Sport Association)
Address:	.…………………………………………………….…………………….…………………..
tel. /fax:	………………………………………………….…………………………………..………..
e-mail:		 ……………………………………………………………………………………..………..
Transmission of the results to the Payer: 	Yes			No
We are committing oneself to paying a fee for conducted analyses after receiving the invoice.
Data the invoice (Payer):
Organization name:		 ……………………………….…….…………………….…………………..
Address:			 …………………….………………………………………………..……….. VAT identification number :	 ………………………….………….…………………….…………………..
telephone:			 …………………………….………………………………………..………..
………………………………………………….   
(stamp and of  ordering person)