Eurofins MicroSafe Laboratories

Darwinweg 24, 2333 CR Leiden, the Netherlands

Tel +31 (0)71 408 3700; www.sinensislifesciences.com

E-mail:

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SAMPLE SUBMISSION FORM

ü  Please use one form per sample

ü  Please fill out the forms digitally

ü  All fields must be completed; missing or incomplete information may delay adequate processing of your request

1.  Sponsor information

Company name / Customer code
Contact person / Purchase Order nr.
E-mail / Direct telephone

2.  Sample information

Name or code
Lot nr.
Number of units
Quantity per unit
Product description
Does the sample contain antibiotics? / NO / YES
Does the sample contain preservatives? / NO / YES

3.  Safety information

Are chemical safety considerations applicable? / NO / YES
If yes, please provide relevant information:
What is the required biosafety level? / None / BSL-1 / BSL-2
Does the sample contain Genetically Modified Organisms? / NO / YES
If yes, please provide the following information:
GMO registration number
Host cell type
Vector used
Source gene and species
Other relevant information

4.  Transport and storage

Transport conditions: / Liquid N2 / Dry ice / Frozen (minus 25°C – minus 15°C)
Cooled (2°C – 8°C) / Room temperature (15°C – 25°C)
Temperature logger present? / NO / YES
Storage conditions: / Liquid N2 * / Dry ice / Frozen (minus 25°C – minus 15°C)
Cooled (2°C – 8°C) / Room temperature (15°C – 25°C)

* only available for long-term storage of cell banks

SAMPLE SUBMISSION FORM

5.  Test requirements

Required test (e.g. sterility test using direct inoculation method according to the EP/USP, mycoplasma test according to the 21CFR/CBER guidelines):
Protocol number (if applicable)
Product specification:
Validation reference (if applicable)
Quotation number:
Other relevant information:
To be completed by MicroSafe:
Sample number / Date of receipt / Recipient’s initials