FOR WUXI APPTEC USE ONLY

 

 

 

Hidden text used for the question mark

A printed copy of this form must accompany articles submitted for testing.

Use shipping address as directed in the relevant protocol.

NOTE: This form can accommodate up to 8 test, comparison, and/or control articles.
If more articles are to be included in the same shipment, use additional Article Submission forms.

 

PAYMENT METHOD  (Required)

 

 

Be sure to complete all fields as appropriate. You will receive an

automatic warning if your form is incomplete when you try to print.

NOTE: Submitting an incomplete form will result in a testing delay.

WARNING: This form is incomplete / missing required information.

Submitting an incomplete form to WuXi AppTec will delay your testing.

If you need assistance, contact your Account Manager.

To print/save, always use the Print/Save button at the bottom of this form.

This will help ensure your form is not incomplete/missing required information that could delay your testing.

 

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

 

PROTOCOL NUMBER  

 

 SPONSOR INFORMATION

 

Account Number

COMPANY NAME • STREET ADDRESS • CITY / STATE / ZIP   *EDITED*

CONTACT NAME / TITLE

PHONE

EMAIL

 

Does this shipment contain study supplies?  

 

 

  Yes – ONLY study supplies                Yes – along with test, comparison, and/or control article(s)                No

 

Study supplies included: 

 

Complete page(s) following to provide required information regarding submitted article(s).

 

FORM-01353

WuXi

•         Page 1 of 2

Effective Date: 04.14.17

ARTICLE INFORMATION

 

The article described below is a:      Test Article         Comparison Article         Control Article

 

Will article described here be shipped to WuXi AppTec from a third party?  

Yes         No

Name of third party:               Estimated arrival date at WuXi AppTec: 

If article will be coming from a third party, email a copy of this entire completed form to the WuXi AppTec study director.

 

ARTICLE INFORMATION

ARTICLE IDENTIFICATION  (As described in the protocol and/or as labeled on the vessel)

QUANTITY SUBMITTED

UNIT OF
MEASURE

LOT NUMBER: 
Multiple (LIST ATTACHED)               N.A.

Limit of 25 characters for lot number.  To provide other identifiers to be specified in final report, enter in “Identification” field above.

EXPIRATION DATE

Multiple (LIST ATTACHED)

STERILIZATION EXPOSURE

Has article been exposed to a sterilization process?    Yes    No

  

STERILITY STATUS OF ARTICLE

 

Select one of the four options shown.

 

  Article submitted sterile.     To be tested as is.

  Article consists of both sterile and non-sterile components.     To be tested as is.

  Article is not sterile.     To be tested non-sterile.

  Article is not sterile. WuXi AppTec to expose to a sterilization cycle. Additional fees apply.

       

 

CHARACTERIZATION INFORMATION

Characterization information for the article, such as strength, homogeneity, purity and stability, and others that may directly impact the testing performed:

IS ATTACHED to this sample submission form.                       is unavailable.                      is considered proprietary information.

 

SAFETY PRECAUTIONS

  

 

SHIPPING & STORAGE

 

 

SPONSOR’S SHIPPING CONDITIONS

CONTROLLED STORAGE CONDITIONS

Specify: 

Additional fee applies

SHIPPING CONDITIONS FOR RETURNS  

 

DISPOSITION (upon test completion)

COURIER AND ACCOUNT # FOR SHIPPING: 

[Required for returns. Additional fees may apply.]

 

Check here if additional article(s) are being submitted in this shipment.
    [If checked, you will see an additional section that must be completed.]

 

FORM-01353

WuXi

•         Page X of Y

Effective Date: 04.14.17

ARTICLE INFORMATION

 

The article described below is a:      Test Article         Comparison Article         Control Article

 

Will article described here be shipped to WuXi AppTec from a third party?  

Yes         No

Name of third party:               Estimated arrival date at WuXi AppTec: 

If article will be coming from a third party, email a copy of this entire completed form to the WuXi AppTec study director.

 

ARTICLE INFORMATION

ARTICLE IDENTIFICATION  (As described in the protocol and/or as labeled on the vessel)

QUANTITY SUBMITTED

UNIT OF
MEASURE

LOT NUMBER: 
Multiple (LIST ATTACHED)               N.A.

Limit of 25 characters for lot number.  To provide other identifiers to be specified in final report, enter in “Identification” field above.

EXPIRATION DATE

Multiple (LIST ATTACHED)

STERILIZATION EXPOSURE

Has article been exposed to a sterilization process?    Yes    No

  

STERILITY STATUS OF ARTICLE

 

Select one of the four options shown.

 

  Article submitted sterile.     To be tested as is.

  Article consists of both sterile and non-sterile components.     To be tested as is.

  Article is not sterile.     To be tested non-sterile.

  Article is not sterile. WuXi AppTec to expose to a sterilization cycle. Additional fees apply.

       

 

CHARACTERIZATION INFORMATION

Characterization information for the article, such as strength, homogeneity, purity and stability, and others that may directly impact the testing performed:

IS ATTACHED to this sample submission form.                       is unavailable.                      is considered proprietary information.

 

SAFETY PRECAUTIONS

  

 

SHIPPING & STORAGE

 

 

SPONSOR’S SHIPPING CONDITIONS

CONTROLLED STORAGE CONDITIONS

Specify: 

Additional fee applies

SHIPPING CONDITIONS FOR RETURNS  

 

DISPOSITION (upon test completion)

COURIER AND ACCOUNT # FOR SHIPPING: 

[Required for returns. Additional fees may apply.]

 

Check here if additional article(s) are being submitted in this shipment.
    [If checked, you will see an additional section that must be completed.]

 

FORM-01353

WuXi

•         Page X of Y

Effective Date: 04.14.17

ARTICLE INFORMATION

 

The article described below is a:      Test Article         Comparison Article         Control Article

 

Will article described here be shipped to WuXi AppTec from a third party?  

Yes         No

Name of third party:               Estimated arrival date at WuXi AppTec: 

If article will be coming from a third party, email a copy of this entire completed form to the WuXi AppTec study director.

 

ARTICLE INFORMATION

ARTICLE IDENTIFICATION  (As described in the protocol and/or as labeled on the vessel)

QUANTITY SUBMITTED

UNIT OF
MEASURE

LOT NUMBER: 
Multiple (LIST ATTACHED)               N.A.

Limit of 25 characters for lot number.  To provide other identifiers to be specified in final report, enter in “Identification” field above.

EXPIRATION DATE

Multiple (LIST ATTACHED)

STERILIZATION EXPOSURE

Has article been exposed to a sterilization process?    Yes    No

  

STERILITY STATUS OF ARTICLE

 

Select one of the four options shown.

 

  Article submitted sterile.     To be tested as is.

  Article consists of both sterile and non-sterile components.     To be tested as is.

  Article is not sterile.     To be tested non-sterile.

  Article is not sterile. WuXi AppTec to expose to a sterilization cycle. Additional fees apply.

       

 

CHARACTERIZATION INFORMATION

Characterization information for the article, such as strength, homogeneity, purity and stability, and others that may directly impact the testing performed:

IS ATTACHED to this sample submission form.                       is unavailable.                      is considered proprietary information.

 

SAFETY PRECAUTIONS

  

 

SHIPPING & STORAGE

 

 

SPONSOR’S SHIPPING CONDITIONS

CONTROLLED STORAGE CONDITIONS

Specify: 

Additional fee applies

SHIPPING CONDITIONS FOR RETURNS  

 

DISPOSITION (upon test completion)

COURIER AND ACCOUNT # FOR SHIPPING: 

[Required for returns. Additional fees may apply.]

 

Check here if additional article(s) are being submitted in this shipment.
    [If checked, you will see an additional section that must be completed.]

 

FORM-01353

WuXi

•         Page X of Y

Effective Date: 04.14.17

ARTICLE INFORMATION

 

The article described below is a:      Test Article         Comparison Article         Control Article

 

Will article described here be shipped to WuXi AppTec from a third party?  

Yes         No

Name of third party:               Estimated arrival date at WuXi AppTec: 

If article will be coming from a third party, email a copy of this entire completed form to the WuXi AppTec study director.

 

ARTICLE INFORMATION

ARTICLE IDENTIFICATION  (As described in the protocol and/or as labeled on the vessel)

QUANTITY SUBMITTED

UNIT OF
MEASURE

LOT NUMBER: 
Multiple (LIST ATTACHED)               N.A.

Limit of 25 characters for lot number.  To provide other identifiers to be specified in final report, enter in “Identification” field above.

EXPIRATION DATE

Multiple (LIST ATTACHED)

STERILIZATION EXPOSURE

Has article been exposed to a sterilization process?    Yes    No

  

STERILITY STATUS OF ARTICLE

 

Select one of the four options shown.

 

  Article submitted sterile.     To be tested as is.

  Article consists of both sterile and non-sterile components.     To be tested as is.

  Article is not sterile.     To be tested non-sterile.

  Article is not sterile. WuXi AppTec to expose to a sterilization cycle. Additional fees apply.

       

 

CHARACTERIZATION INFORMATION

Characterization information for the article, such as strength, homogeneity, purity and stability, and others that may directly impact the testing performed:

IS ATTACHED to this sample submission form.                       is unavailable.                      is considered proprietary information.

 

SAFETY PRECAUTIONS

  

 

SHIPPING & STORAGE

 

 

SPONSOR’S SHIPPING CONDITIONS

CONTROLLED STORAGE CONDITIONS

Specify: 

Additional fee applies

SHIPPING CONDITIONS FOR RETURNS  

 

DISPOSITION (upon test completion)

COURIER AND ACCOUNT # FOR SHIPPING: 

[Required for returns. Additional fees may apply.]

 

Check here if additional article(s) are being submitted in this shipment.
    [If checked, you will see an additional section that must be completed.]

 

FORM-01353

WuXi

•         Page X of Y

Effective Date: 04.14.17

ARTICLE INFORMATION

 

The article described below is a:      Test Article         Comparison Article         Control Article

 

Will article described here be shipped to WuXi AppTec from a third party?  

Yes         No

Name of third party:               Estimated arrival date at WuXi AppTec: 

If article will be coming from a third party, email a copy of this entire completed form to the WuXi AppTec study director.

 

ARTICLE INFORMATION

ARTICLE IDENTIFICATION  (As described in the protocol and/or as labeled on the vessel)

QUANTITY SUBMITTED

UNIT OF
MEASURE

LOT NUMBER: 
Multiple (LIST ATTACHED)               N.A.

Limit of 25 characters for lot number.  To provide other identifiers to be specified in final report, enter in “Identification” field above.

EXPIRATION DATE

Multiple (LIST ATTACHED)

STERILIZATION EXPOSURE

Has article been exposed to a sterilization process?    Yes    No

  

STERILITY STATUS OF ARTICLE

 

Select one of the four options shown.

 

  Article submitted sterile.     To be tested as is.

  Article consists of both sterile and non-sterile components.     To be tested as is.

  Article is not sterile.     To be tested non-sterile.

  Article is not sterile. WuXi AppTec to expose to a sterilization cycle. Additional fees apply.

       

 

CHARACTERIZATION INFORMATION

Characterization information for the article, such as strength, homogeneity, purity and stability, and others that may directly impact the testing performed:

IS ATTACHED to this sample submission form.                       is unavailable.                      is considered proprietary information.

 

SAFETY PRECAUTIONS

  

 

SHIPPING & STORAGE

 

 

SPONSOR’S SHIPPING CONDITIONS

CONTROLLED STORAGE CONDITIONS

Specify: 

Additional fee applies

SHIPPING CONDITIONS FOR RETURNS  

 

DISPOSITION (upon test completion)

COURIER AND ACCOUNT # FOR SHIPPING: 

[Required for returns. Additional fees may apply.]

 

Check here if additional article(s) are being submitted in this shipment.
    [If checked, you will see an additional section that must be completed.]

 

FORM-01353

WuXi

•         Page X of Y

Effective Date: 04.14.17

ARTICLE INFORMATION

 

The article described below is a:      Test Article         Comparison Article         Control Article

 

Will article described here be shipped to WuXi AppTec from a third party?  

Yes         No

Name of third party:               Estimated arrival date at WuXi AppTec: 

If article will be coming from a third party, email a copy of this entire completed form to the WuXi AppTec study director.

 

ARTICLE INFORMATION

ARTICLE IDENTIFICATION  (As described in the protocol and/or as labeled on the vessel)

QUANTITY SUBMITTED

UNIT OF
MEASURE

LOT NUMBER: 
Multiple (LIST ATTACHED)               N.A.

Limit of 25 characters for lot number.  To provide other identifiers to be specified in final report, enter in “Identification” field above.

EXPIRATION DATE

Multiple (LIST ATTACHED)

STERILIZATION EXPOSURE

Has article been exposed to a sterilization process?    Yes    No

  

STERILITY STATUS OF ARTICLE

 

Select one of the four options shown.

 

  Article submitted sterile.     To be tested as is.

  Article consists of both sterile and non-sterile components.     To be tested as is.

  Article is not sterile.     To be tested non-sterile.

  Article is not sterile. WuXi AppTec to expose to a sterilization cycle. Additional fees apply.

       

 

CHARACTERIZATION INFORMATION

Characterization information for the article, such as strength, homogeneity, purity and stability, and others that may directly impact the testing performed:

IS ATTACHED to this sample submission form.                       is unavailable.                      is considered proprietary information.

 

SAFETY PRECAUTIONS

  

 

SHIPPING & STORAGE

 

 

SPONSOR’S SHIPPING CONDITIONS

CONTROLLED STORAGE CONDITIONS

Specify: 

Additional fee applies

SHIPPING CONDITIONS FOR RETURNS  

 

DISPOSITION (upon test completion)

COURIER AND ACCOUNT # FOR SHIPPING: 

[Required for returns. Additional fees may apply.]

 

Check here if additional article(s) are being submitted in this shipment.
    [If checked, you will see an additional section that must be completed.]

 

FORM-01353

WuXi

•         Page X of Y

Effective Date: 04.14.17

ARTICLE INFORMATION

 

The article described below is a:      Test Article         Comparison Article         Control Article

 

Will article described here be shipped to WuXi AppTec from a third party?  

Yes         No

Name of third party:               Estimated arrival date at WuXi AppTec: 

If article will be coming from a third party, email a copy of this entire completed form to the WuXi AppTec study director.

 

ARTICLE INFORMATION

ARTICLE IDENTIFICATION  (As described in the protocol and/or as labeled on the vessel)

QUANTITY SUBMITTED

UNIT OF
MEASURE

LOT NUMBER: 
Multiple (LIST ATTACHED)               N.A.

Limit of 25 characters for lot number.  To provide other identifiers to be specified in final report, enter in “Identification” field above.

EXPIRATION DATE

Multiple (LIST ATTACHED)

STERILIZATION EXPOSURE

Has article been exposed to a sterilization process?    Yes    No

  

STERILITY STATUS OF ARTICLE

 

Select one of the four options shown.

 

  Article submitted sterile.     To be tested as is.

  Article consists of both sterile and non-sterile components.     To be tested as is.

  Article is not sterile.     To be tested non-sterile.

  Article is not sterile. WuXi AppTec to expose to a sterilization cycle. Additional fees apply.

       

 

CHARACTERIZATION INFORMATION

Characterization information for the article, such as strength, homogeneity, purity and stability, and others that may directly impact the testing performed:

IS ATTACHED to this sample submission form.                       is unavailable.                      is considered proprietary information.

 

SAFETY PRECAUTIONS

  

 

SHIPPING & STORAGE

 

 

SPONSOR’S SHIPPING CONDITIONS

CONTROLLED STORAGE CONDITIONS

Specify: 

Additional fee applies

SHIPPING CONDITIONS FOR RETURNS  

 

DISPOSITION (upon test completion)

COURIER AND ACCOUNT # FOR SHIPPING: 

[Required for returns. Additional fees may apply.]

 

Check here if additional article(s) are being submitted in this shipment.
    [If checked, you will see an additional section that must be completed.]

 

FORM-01353

WuXi

•         Page X of Y

Effective Date: 04.14.17

ARTICLE INFORMATION

 

The article described below is a:      Test Article         Comparison Article         Control Article

 

Will article described here be shipped to WuXi AppTec from a third party?  

Yes         No

Name of third party:               Estimated arrival date at WuXi AppTec: 

If article will be coming from a third party, email a copy of this entire completed form to the WuXi AppTec study director.

 

ARTICLE INFORMATION

ARTICLE IDENTIFICATION  (As described in the protocol and/or as labeled on the vessel)

QUANTITY SUBMITTED

UNIT OF
MEASURE

LOT NUMBER: 
Multiple (LIST ATTACHED)               N.A.

Limit of 25 characters for lot number.  To provide other identifiers to be specified in final report, enter in “Identification” field above.

EXPIRATION DATE

Multiple (LIST ATTACHED)

STERILIZATION EXPOSURE

Has article been exposed to a sterilization process?    Yes    No

  

STERILITY STATUS OF ARTICLE

 

Select one of the four options shown.

 

  Article submitted sterile.     To be tested as is.

  Article consists of both sterile and non-sterile components.     To be tested as is.

  Article is not sterile.     To be tested non-sterile.

  Article is not sterile. WuXi AppTec to expose to a sterilization cycle. Additional fees apply.

       

 

CHARACTERIZATION INFORMATION

Characterization information for the article, such as strength, homogeneity, purity and stability, and others that may directly impact the testing performed:

IS ATTACHED to this sample submission form.                       is unavailable.                      is considered proprietary information.

 

SAFETY PRECAUTIONS

  

 

SHIPPING & STORAGE

 

 

SPONSOR’S SHIPPING CONDITIONS

CONTROLLED STORAGE CONDITIONS

Specify: 

Additional fee applies

SHIPPING CONDITIONS FOR RETURNS  

 

DISPOSITION (upon test completion)

COURIER AND ACCOUNT # FOR SHIPPING: 

[Required for returns. Additional fees may apply.]

 

FORM-01353

WuXi

•         Page X of Y

Effective Date: 04.14.17

COMMENTS

(Provide additional information as needed.  Attach additional pages if necessary.)

 

FORM COMPLETED BY:

 

 

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
.

 

 

 

 

NAME

 

DATE

 

 

Select shipping destination/where testing will be conducted:

WuXi AppTec - St. Paul • 2540 Executive Drive • St. Paul, MN 55120

WuXi AppTec - Atlanta • 1265 Kennestone Circle • Marietta, GA 30066

 

An electronic copy of the report will be emailed to you after the study has been completed.

Do you require a hard copy of the report?

Yes, send the hard copy via courier.

No, an electronic copy is sufficient.
(The original hard copy of the report will be archived at WuXi AppTec and can be sent to you at any time upon request.)

 

FORM-01353

WuXi

•         Page 2 of 2

Effective Date: 04.14.17