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