QUOTE # (QUO ##### - ###### - #) QUO - - - |
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PROTOCOL NUMBER |
Account Number (required) |
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PAYMENT METHOD
(required)
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CLIENT INFORMATION |
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COMPANY NAME & ADDRESS
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CONTACT FOR FINAL REPORT: |
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PHONE: |
EMAIL: |
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SECONDARY CONTACT (if applicable/needed): |
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PHONE: |
EMAIL: |
TEST ARTICLE INFORMATION |
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Molecule / Product Name:
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Stage of Submission:
Describe:
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Type of
Describe:
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Species:
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Cell Line:
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Comments / Special Instructions |
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Complete this form on the
following pages by providing additional information |
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:03 |
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) For storage conditions after thawing: if not applicable, indicate “NA” |
Test Article Identification on Label |
Equivalent
Test Article Listed in |
Test Article Matrix / Buffer Conditions (concentration, pH, conductivity, etc) |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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FORM-00565 |
WuXi |
• Page 2 of 4 |
Revision:03 |
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) For storage conditions after thawing: if not applicable, indicate “NA” |
Test Article Identification on Label |
Equivalent
Test Article Listed in |
Test Article Matrix / Buffer Conditions (concentration, pH, conductivity, etc) |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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FORM-00565 |
WuXi |
• Page X of Y |
Revision:03 |
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) For storage conditions after thawing: if not applicable, indicate “NA” |
Test Article Identification on Label |
Equivalent
Test Article Listed in |
Test Article Matrix / Buffer Conditions (concentration, pH, conductivity, etc) |
|
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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FORM-00565 |
WuXi |
• Page X of Y |
Revision:03 |
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) For storage conditions after thawing: if not applicable, indicate “NA” |
Test Article Identification on Label |
Equivalent
Test Article Listed in |
Test Article Matrix / Buffer Conditions (concentration, pH, conductivity, etc) |
|
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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FORM-00565 |
WuXi |
• Page X of Y |
Revision:03 |
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) For storage conditions after thawing: if not applicable, indicate “NA” |
Test Article Identification on Label |
Equivalent
Test Article Listed in |
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; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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FORM-00565 |
WuXi |
• Page X of Y |
Revision:03 |
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) For storage conditions after thawing: if not applicable, indicate “NA” |
Test Article Identification on Label |
Equivalent
Test Article Listed in |
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; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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# of containers: Volume per container: Storage conditions: Storage conditions after thawing: Remaining material to be returned? Indicate YES or NO; |
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FORM-00565 |
WuXi |
• Page X of Y |
Revision:03 |
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 |
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WUXI APPTEC USE ONLY |
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Material Identification |
# of Containers |
Volume per Container (if applicable) |
Storage Conditions |
Buffer Conditions (concentration, pH, conductivity, etc) |
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CHECK –
RECEIVED |
CHECK – RECEIVED
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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: |
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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:03 |
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 |
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WUXI APPTEC USE ONLY |
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Material Identification |
# of Containers |
Volume per Container (if applicable) |
Storage Conditions |
Buffer Conditions (concentration, pH, conductivity, etc) |
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CHECK –
RECEIVED |
CHECK – RECEIVED
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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: |
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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:03 |
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 |
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WUXI APPTEC USE ONLY |
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Material Identification |
# of Containers |
Volume per Container (if applicable) |
Storage Conditions |
Buffer Conditions (concentration, pH, conductivity, etc) |
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CHECK –
RECEIVED |
CHECK – RECEIVED
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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: |
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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:03 |
IMPORTANT
INSTRUCTIONS REGARDING THIS FORM. |
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 |
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To save
an electronic copy in your print dialog.
Always print a hard copy |
SIGNATURE (REQUIRED) |
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PRINT NAME |
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DATE |
FORM-00565 |
WuXi |
• Page 4 of 4 |
Revision:03 |