FOR MINARIS ADVANCED THERAPIES 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:07

TEST ARTICLES IN SHIPMENT

To describe storage conditions, use the following abbreviations:

A = Ambient      R = Refrigerated (2° to 8°C)      F = Frozen (-10° to -20°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
Minaris Advanced Therapies 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:07

TEST ARTICLES IN SHIPMENT

To describe storage conditions, use the following abbreviations:

A = Ambient      R = Refrigerated (2° to 8°C)      F = Frozen (-10° to -20°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
Minaris Advanced Therapies 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:07

TEST ARTICLES IN SHIPMENT

To describe storage conditions, use the following abbreviations:

A = Ambient      R = Refrigerated (2° to 8°C)      F = Frozen (-10° to -20°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
Minaris Advanced Therapies 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:07

TEST ARTICLES IN SHIPMENT

To describe storage conditions, use the following abbreviations:

A = Ambient      R = Refrigerated (2° to 8°C)      F = Frozen (-10° to -20°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
Minaris Advanced Therapies 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:07

TEST ARTICLES IN SHIPMENT

To describe storage conditions, use the following abbreviations:

A = Ambient      R = Refrigerated (2° to 8°C)      F = Frozen (-10° to -20°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
Minaris Advanced Therapies 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:07

TEST ARTICLES IN SHIPMENT

To describe storage conditions, use the following abbreviations:

A = Ambient      R = Refrigerated (2° to 8°C)      F = Frozen (-10° to -20°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
Minaris Advanced Therapies 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:07

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 -20°C)      U = Ultracold (< -60°C)      LN = Liquid Nitrogen

 

 

 

 

 

 

 

MINARIS ADVANCED THERAPIES USE ONLY

Material Identification

(Include lot number)

Qty

Volume/

container

Storage Conditions

Buffer Conditions

(concentration, pH, conductivity, exp. date, etc)

 

Login Check

TCU ID

Lab Check

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Login Initial/Date

Lab Initial/Date

 

 

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

 

 

FORM-00565

WuXi

•         Page 3 of 4

Revision:07

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 -20°C)      U = Ultracold (< -60°C)      LN = Liquid Nitrogen

 

 

 

 

 

 

 

MINARIS ADVANCED THERAPIES USE ONLY

Material Identification

(Include lot number)

Qty

Volume/

container

Storage Conditions

Buffer Conditions

(concentration, pH, conductivity, exp. date, etc)

 

Login Check

TCU ID

Lab Check

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Login Initial/Date

Lab Initial/Date

 

 

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

 

 

FORM-00565

WuXi

•         Page X of Y

Revision:07

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 -20°C)      U = Ultracold (< -60°C)      LN = Liquid Nitrogen

 

 

 

 

 

 

 

MINARIS ADVANCED THERAPIES USE ONLY

Material Identification

(Include lot number)

Qty

Volume/

container

Storage Conditions

Buffer Conditions

(concentration, pH, conductivity, exp. date, etc)

 

Login Check

TCU ID

Lab Check

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Login Initial/Date

Lab Initial/Date

 

 

 

 

FORM-00565

WuXi

•         Page X of Y

Revision:07

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 Minaris Advanced Therapies regarding these particular samples.  Failure to provide this information could result in testing delays or other issues. Minaris Advanced Therapies will not be held responsible for information not provided by client. Services requested in this form will be governed in accordance with Minaris Advanced Therapies's “Standard Terms and Conditions.”  To the extent Minaris Advanced Therapies's Standard Terms and Conditions are in conflict with an applicable agreement (Agreement) between Customer listed in this form and Minaris Advanced Therapies, 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:07