FOR WUXI APPTEC USE ONLY

 

 

PAYMENT METHOD 

REQUIRED: All applicable information must be completed on this
form and a print copy must be included in your test article shipment.

SHIP TO: WuXi AppTec • 2540 Executive Drive • St. Paul, MN 55120

(1) 651.675.2000 TOLL FREE 888.794.0077

 

This form is incomplete / missing required information

and is not ready for submission to WuXi AppTec.

 

This form may be incomplete / missing required information

and is not ready for submission to WuXi AppTec.

Please use the Print/Save button at the bottom of the form.

Used for extra space

 

QUOTE NUMBER  (QUO - ##### - ###### - #)

 

QUO - - -

 

 CLIENT INFORMATION

 

Account Number

COMPANY NAME • STREET ADDRESS • CITY / STATE / ZIP

CONTACT NAME

PHONE

EMAIL

 

 REQUESTED TESTING

 

QTY TO BE TESTED

TEST CODE

TEST NAME

 

TEST ARTICLE INFORMATION

TOTAL NUMBER OF TEST ARTICLES IN SHIPMENT: 

TEST ARTICLE NAME  (Exact wording will be used on reports.)

SAMPLE ID NUMBERS (Batch, Lot, Load, etc.)

EXPIRATION
DATE

 

CONTROLLED STORAGE CONDITIONS

 

SAFETY PRECAUTIONS

 

STERILITY   
Is article submitted sterile?   Yes No

 

 TEST ARTICLE PREPARATION & HANDLING

(Provide information if applicable.  Attach additional pages if necessary.)

Preparation Instructions and Additional Comments               N.A.

Can the test
article be cut?

 

 

SURFACE AREA

MEASUREMENT

Per test article or group of component(s) for each extract:

 

cm2     N.A.

NOTE:  Entire article will be tested unless information is provided here as to materials/components to be included/excluded for testing.

 

TEST ARTICLE DISPOSITION

(NOTE:  Additional fee may apply for returns.)

Courier and account # for shipping:

(Required for returns)

 

 

  Check here if comparison/control article is being submitted.     [If checked, you will see an additional section that must be completed.]

 

Services requested in this form will be governed in accordance with WuXi AppTec's “Standard Terms and Conditions.”  To the extent WuXi AppTec's Standard Terms and Conditions are in conflict with an applicable agreement (Agreement) between Customer listed in this form and WuXi AppTec, such Agreement will govern.

 

 

 

To save an electronic copy
of this completed form, select
Adobe PDF Writer or
Microsoft XPS Document Writer

in your print dialog.

 

Always print a hard copy
to ship with your samples.

 TESTING AUTHORIZATION

Sponsor signature is required before testing will be initiated.

 

 

 

 

 

 

SIGNATURE

 

PRINT NAME

 

DATE

 

 

ALS-8000-14.05

ID 12345 ABCDE 6789

•         Page 1 of 1

Effective Date:  04.15.16

COMPARISON / CONTROL ARTICLE INFORMATION

TOTAL NUMBER OF CONTROL ARTICLES IN SHIPMENT: 

COMPARISON / CONTROL ARTICLE NAME  (Exact wording will be used on reports.)

SAMPLE ID NUMBERS (Batch, Lot, Load, etc.)

EXPIRATION DATE

 

CONTROLLED STORAGE CONDITIONS

 

SAFETY PRECAUTIONS

 

STERILITY  
Is control article submitted sterile?   Yes No

 

CONTROL ARTICLE PREPARATION & HANDLING

(Provide information if applicable.  Attach additional pages if necessary.)

Preparation Instructions and Additional Comments               N.A.

Can the test
article be cut?

 

 

SURFACE AREA

MEASUREMENT

Per test article or group of component(s) for each extract:

 

cm2     N.A.

NOTE:  Entire article will be tested unless information is provided here as to materials/components to be included/excluded for testing.

 

COMPARISON / CONTROL
ARTICLE DISPOSITION

(NOTE:  Additional fee may apply for returns.)

Courier and account # for shipping:

(Required for returns)

 

 

Services requested in this form will be governed in accordance with WuXi AppTec's “Standard Terms and Conditions.”  To the extent WuXi AppTec's Standard Terms and Conditions are in conflict with an applicable agreement (Agreement) between Customer listed in this form and WuXi AppTec, such Agreement will govern.

 

 

 

To save an electronic copy
of this completed form, select
Adobe PDF Writer or
Microsoft XPS Document Writer

in your print dialog.

 

Always print a hard copy
to ship with your samples.

 TESTING AUTHORIZATION

Sponsor signature is required before testing will be initiated.

 

 

 

 

 

 

SIGNATURE

 

PRINT NAME

 

DATE

 

 

ALS-8000-14.05

ID 12345 ABCDE 6789

•         Page X of Y

Effective Date:  04.15.16