FOR WUXI APPTEC USE ONLY

LIMS SAMPLE #

 

 

 

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

 

PROTOCOL NUMBER  

 

Account Number (required)  

 

PAYMENT METHOD (required)

 

 

CLIENT INFORMATION

 

 

COMPANY NAME & ADDRESS

CONTACT FOR FINAL REPORT: 

       PHONE: 

EMAIL: 

SECONDARY CONTACT (if applicable/needed): 

       PHONE: 

EMAIL:  

 

 

TEST ARTICLE INFORMATION

 

Molecule / Product Name:

Stage of Submission:

 

 

Type of
Regulatory Filing:

 

 

Species:

Cell Line:

 

 

Comments / Special Instructions

 

 

 

Complete this form on the following pages by providing additional information
for test articles – and other materials – being submitted.

 

Print out and include in the shipment as many pages as needed to supply all information.

 

Be sure to sign and include SIGNATURE PAGE (last page of this form).

 

FORM-00565

WuXi

•         Page 1 of 4

Revision:02

TEST ARTICLES IN SHIPMENT

To describe storage conditions, use the following abbreviations:

A = Ambient      R = Refrigerated (2° to 8°C)      F = Frozen (-10° to -60°C)      
U = Ultracold (< -60°C)      LN = Liquid Nitrogen

For storage conditions after thawing:  if not applicable, indicate “NA”

 

Test Article Identification on Label

Equivalent Test Article Listed in
WuXi AppTec Protocol

Test Article Matrix / Buffer Conditions

(concentration, pH, conductivity, etc)

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

 

   Check here if more space is needed to list test articles being submitted.  An additional page will be displayed.

 

FORM-00565

WuXi

•         Page 2 of 4

Revision:02

TEST ARTICLES IN SHIPMENT

To describe storage conditions, use the following abbreviations:

A = Ambient      R = Refrigerated (2° to 8°C)      F = Frozen (-10° to -60°C)      
U = Ultracold (< -60°C)      LN = Liquid Nitrogen

For storage conditions after thawing:  if not applicable, indicate “NA”

 

Test Article Identification on Label

Equivalent Test Article Listed in
WuXi AppTec Protocol

Test Article Matrix / Buffer Conditions

(concentration, pH, conductivity, etc)

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

 

   Check here if more space is needed to list test articles being submitted.  An additional page will be displayed.

 

FORM-00565

WuXi

•         Page X of Y

Revision:02

TEST ARTICLES IN SHIPMENT

To describe storage conditions, use the following abbreviations:

A = Ambient      R = Refrigerated (2° to 8°C)      F = Frozen (-10° to -60°C)      
U = Ultracold (< -60°C)      LN = Liquid Nitrogen

For storage conditions after thawing:  if not applicable, indicate “NA”

 

Test Article Identification on Label

Equivalent Test Article Listed in
WuXi AppTec Protocol

Test Article Matrix / Buffer Conditions

(concentration, pH, conductivity, etc)

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

 

   Check here if more space is needed to list test articles being submitted.  An additional page will be displayed.

 

FORM-00565

WuXi

•         Page X of Y

Revision:02

TEST ARTICLES IN SHIPMENT

To describe storage conditions, use the following abbreviations:

A = Ambient      R = Refrigerated (2° to 8°C)      F = Frozen (-10° to -60°C)      
U = Ultracold (< -60°C)      LN = Liquid Nitrogen

For storage conditions after thawing:  if not applicable, indicate “NA”

 

Test Article Identification on Label

Equivalent Test Article Listed in
WuXi AppTec Protocol

Test Article Matrix / Buffer Conditions

(concentration, pH, conductivity, etc)

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

 

   Check here if more space is needed to list test articles being submitted.  An additional page will be displayed.

 

FORM-00565

WuXi

•         Page X of Y

Revision:02

TEST ARTICLES IN SHIPMENT

To describe storage conditions, use the following abbreviations:

A = Ambient      R = Refrigerated (2° to 8°C)      F = Frozen (-10° to -60°C)      
U = Ultracold (< -60°C)      LN = Liquid Nitrogen

For storage conditions after thawing:  if not applicable, indicate “NA”

 

Test Article Identification on Label

Equivalent Test Article Listed in
WuXi AppTec Protocol

Test Article Matrix / Buffer Conditions

(concentration, pH, conductivity, etc)

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

 

   Check here if more space is needed to list test articles being submitted.  An additional page will be displayed.

 

FORM-00565

WuXi

•         Page X of Y

Revision:02

TEST ARTICLES IN SHIPMENT

To describe storage conditions, use the following abbreviations:

A = Ambient      R = Refrigerated (2° to 8°C)      F = Frozen (-10° to -60°C)      
U = Ultracold (< -60°C)      LN = Liquid Nitrogen

For storage conditions after thawing:  if not applicable, indicate “NA”

 

Test Article Identification on Label

Equivalent Test Article Listed in
WuXi AppTec Protocol

Test Article Matrix / Buffer Conditions

(concentration, pH, conductivity, etc)

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

# of containers:       Volume per container:       Storage conditions:          Storage conditions after thawing:       Remaining material to be returned?

Indicate YES or NO; 

 

 

FORM-00565

WuXi

•         Page X of Y

Revision:02

Complete the information below for items in shipment – other than test articles – that will be used in the viral clearance studies
(e.g., buffers, columns, resins, filters).  Note that consumables sent on behalf of the Sponsor do not need to be included on this form.

 

 

OTHER MATERIALS IN SHIPMENT

To describe storage conditions, use the following abbreviations:

A = Ambient      R = Refrigerated (2° to 8°C)      F = Frozen (-10° to -60°C)      U = Ultracold (< -60°C)      LN = Liquid Nitrogen

 

 

 

 

 

 

 

WUXI APPTEC USE ONLY

Material Identification

# of

Containers

Volume per Container

(if applicable)

Storage Conditions

Buffer Conditions

(concentration, pH, conductivity, etc)

 

CHECK – RECEIVED
BY LOG IN

CHECK – RECEIVED
BY LAB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check here if more space is needed to list materials being submitted. 
      An additional page will be displayed.

 

WUXI APPTEC USE ONLY — To be completed by lab with storage unit and initial / date

Material to be stored at ambient temperature was stored in unit:

 

Material to be stored at 2-8°C was stored in unit:

WUXI APPTEC USE ONLY — Received by Log-In  •  Initial / Date:

Material to be stored at ≤-60°C was stored in unit:

 

FORM-00565

WuXi

•         Page 3 of 4

Revision:02

Complete the information below for items in shipment – other than test articles – that will be used in the viral clearance studies
(e.g., buffers, columns, resins, filters).  Note that consumables sent on behalf of the Sponsor do not need to be included on this form.

 

 

OTHER MATERIALS IN SHIPMENT

To describe storage conditions, use the following abbreviations:

A = Ambient      R = Refrigerated (2° to 8°C)      F = Frozen (-10° to -60°C)      U = Ultracold (< -60°C)      LN = Liquid Nitrogen

 

 

 

 

 

 

 

WUXI APPTEC USE ONLY

Material Identification

# of

Containers

Volume per Container

(if applicable)

Storage Conditions

Buffer Conditions

(concentration, pH, conductivity, etc)

 

CHECK – RECEIVED
BY LOG IN

CHECK – RECEIVED
BY LAB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check here if more space is needed to list materials being submitted. 
      An additional page will be displayed.

 

WUXI APPTEC USE ONLY — To be completed by lab with storage unit and initial / date

Material to be stored at ambient temperature was stored in unit:

 

Material to be stored at 2-8°C was stored in unit:

WUXI APPTEC USE ONLY — Received by Log-In  •  Initial / Date:

Material to be stored at ≤-60°C was stored in unit:

 

FORM-00565

WuXi

•         Page X of Y

Revision:02

Complete the information below for items in shipment – other than test articles – that will be used in the viral clearance studies
(e.g., buffers, columns, resins, filters).  Note that consumables sent on behalf of the Sponsor do not need to be included on this form.

 

 

OTHER MATERIALS IN SHIPMENT

To describe storage conditions, use the following abbreviations:

A = Ambient      R = Refrigerated (2° to 8°C)      F = Frozen (-10° to -60°C)      U = Ultracold (< -60°C)      LN = Liquid Nitrogen

 

 

 

 

 

 

 

WUXI APPTEC USE ONLY

Material Identification

# of

Containers

Volume per Container

(if applicable)

Storage Conditions

Buffer Conditions

(concentration, pH, conductivity, etc)

 

CHECK – RECEIVED
BY LOG IN

CHECK – RECEIVED
BY LAB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WUXI APPTEC USE ONLY — To be completed by lab with storage unit and initial / date

Material to be stored at ambient temperature was stored in unit:

 

Material to be stored at 2-8°C was stored in unit:

WUXI APPTEC USE ONLY — Received by Log-In  •  Initial / Date:

Material to be stored at ≤-60°C was stored in unit:

 

FORM-00565

WuXi

•         Page X of Y

Revision:02

IMPORTANT INSTRUCTIONS REGARDING THIS FORM.
READ CAREFULLY BEFORE SIGNING AUTHORIZATION BELOW.

This sample submission form – which must accompany each submitted sample – acts as the official record for what is being requested/required of WuXi AppTec regarding these particular samples.  Failure to provide this information could result in testing delays or other issues. WuXi AppTec will not be held responsible for information not provided by client. 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.

 

SAMPLE SUBMISSION AUTHORIZATION

 

 

 

 

 

 

 

 

 

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.

SIGNATURE

(REQUIRED)

 

PRINT NAME

 

DATE

 

FORM-00565

WuXi

•         Page 4 of 4

Revision:02