FOR WUXI APPTEC USE ONLY

 

PAYMENT METHOD  (required):

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 (required):

COMPANY NAME • STREET ADDRESS • CITY / STATE / ZIP

CONTACT NAME

PHONE

EMAIL

 

 REQUESTED TESTING

                  CLICK HERE to view a PDF with listings of available OI tests.

TEST CODE

TEST NAME

 

Enter the test code, hit “Tab” and the test name will automatically populate from our database.
Also, additional form sections will now appear depending on your requested test.

NOTE:
If you are ordering a custom or client-specific assay, you MUST
provide your Quote Number and Account Number above.

 

 

 

 

TEST ARTICLE INFORMATION

TOTAL NUMBER OF TEST ARTICLES IN SHIPMENT: 

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

CONTROLLED STORAGE CONDITIONS

 

LOT / DONOR ID NUMBER

QUANTITY

 

For WuXi AppTec Use Only

PROJECT NUMBER

 

 

 

 

 

 

 

 

 

 

 

Check here if more space is needed to list Lot / Donor ID numbers. An additional page – with space for continued listings – will be added.

 

COMMENTS / SPECIAL HANDLING

 

 

TEST ARTICLE DISPOSITION

 

Courier and account # for shipping:

(Required for returns)

(NOTE: Additional fee may apply for returns.)

TEST ARTICLE INFORMATION

TOTAL NUMBER OF TEST ARTICLES IN SHIPMENT: 

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

LOT NUMBER / DONOR NUMBER

PRODUCT STATE

 

CONTROLLED STORAGE CONDITIONS

 

STERILITY    Is article submitted sterile?       Yes        No

 

OPTIONS FOR TESTING

 

IMPLANT LOCATION – SELECT ONE

 Intramuscular (in muscle pouch):  Biceps femoris   Intermuscular (between muscle pouch):  Adductor brevis and semimembranous
 Intramuscular (in muscle pouch):  Gluteal   Intermuscular (between muscle pouch):  Biceps femoris

AMOUNT OF SAMPLE TO BE IMPLANTED:         per site (i.e., weight, vol)

 

TEST ARTICLE DISPOSITION

 

Courier and account # for shipping:

(Required for returns)

(NOTE: Additional fee may apply for returns.)

 

COMMENTS

 

 

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

 

 

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-8000-8.03

ID 12345 ABCDE 6789

•         Page 1 of 1

Effective Date:  11.18.15

 

TEST ARTICLE INFORMATION

LOT / DONOR ID NUMBERS – CONTINUED

 

LOT / DONOR ID NUMBER

QUANTITY

 

For WuXi AppTec Use Only

PROJECT NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMENTS / SPECIAL HANDLING

 

 

TEST ARTICLE DISPOSITION

 

Courier and account # for shipping:

(Required for returns)

(NOTE: Additional fee may apply 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-8000-8.03

ID 12345 ABCDE 6789

•         Page X of Y

Effective Date:  11.18.15