Sample Submission Form

 

I, ______________________________ do hereby submit a (gold/gold ore) sample designated as _______________ to BlackSand2Gold, LLC, for processing and/or purification.  I hereby declare that I am the rightful owner of said sample and all information concerning the sample should be reported back to me, in confidence, at:

 

Company (if applicable): _______________________________________

Address: ____________________          City: _______________________

State: ______________________  Zip: ___________     Country: __________________

Email: ______________________  

 

Signature: ___________________

Date: _______________________

 

Additional information that may be useful to BlackSand2Gold, LLC (not required):

 

Sample source: _____________________________________________________________________

 

Approx dry weight: _____________________ grams    Approx vol: _________________________cc

 

Mechanical treatment: _______________________________________________________________

 

Chemical treatment: _________________________________________________________________

 

Known (or suspected) hazardous conditions, components, etc: ________________________________

 

__________________________________________________________________________________

 

Other: ____________________________________________________________________________

 

Shipping Address for Samples:

David Gray

3013 Sterling Rd

Augusta, GA 30907

 

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