Customized Request
Name of Product: / To be filled in by Capricorn ScientificCat. No.:
Customer Address
Customer Contact Person
Name:
Phone:
Fax:
E-Mail:
Capricorn Scientific GmbH
Name: Mrs Katrin Richter
E-Mail:
Phone: +49 6424-94464-24
Fax: +49 6424-94464-20
Product Description
Name of product:
Short description:
Liquid - amount to be produced: l
Powder - amount to be produced: g kg l (liquid as powder)
Filling volume: per unit
Requested time of delivery:
Starting Material: Further Description of Formula or List of Components
Please provide data in g/l or mol/l, quality and concentration of components, supplier of raw materials (if necessary) or a reference to a similar product.
Formulation attached*: yes no
Solubility and stability approved by customer: yes no
Starting materials provided by customer: yes no
*After order entry, Capricorn will send the formulation for final approval, which has to be signed and confirmed by the customer.
Intellectual Property
Customer confirms that he/she holds patent yes no
Customer confirms that formulation is either public or not covered by a third party patent yes no
Product Features
Sterile final product yes no
Sterile filtration yes no
Filter size 0.2 µm other
Gamma irradiation yes no
Dosage 25 kGy 35 kGy
min: max:
Heat inactivation (56°C/30 min) yes no
Other methods
Storage Temperature
Room Temperature (+15 to +25°C) Cooled (+2 to +8°C) Frozen (< -15°C)
Dark & Dry (>+2°C) Other:
Transport Conditions
Ambient temp. Cooled truck Freezer truck On dry ice Other:
Packaging Material
Primary packaging (bottle, bag, etc.):
Bottles (PET/PETG) yes no others:
Bottle size 100 ml 500 ml 1000 ml ml
Bags/Others
Description/trade name 10 l 20 l other:
Container for Powder (HDPE) yes no
Suitable to prepare l/liquid or alternatively provide filling size in g/kg of powder:
Primary packaging provided by customer yes no
If yes, describe the packaging and supplier:
Labelling of the product:
1) Capricorn Scientific label yes no
2) Customized label yes no
Material: Size:
Print on label:
Product name:
Product description/Sodium Bicarbonate information (if required):
Volume/Pack size:
Expiry:
Storage temperature:
Other:
Secondary packaging (cardboard, styrofoam)
Standard packaging Capricorn Scientific yes no
If no, describe material and supplier:
Labelling of the cardboard (secondary packaging)
1) Capricorn Scientific label yes no
2) Customized label yes no
Material: Size:
Quality Control
Tests requested by customer: Add range where appropriate; *for powder products w/o NaHCO3
Sterility (liquid only) yes no
pH* yes no specification: to
Osmolality* yes no specification: to mOsmol/kg
Endotoxin* yes no specification: EU/ml
Other:
Documentation
Requested documentation:
Approved by
Name: Sign: Date:
Capricorn Scientific GmbH • Auf der Lette 13 A • 35085 Ebsdorfergrund • Germany Page 1 / 4
Phone: +49 06424 944 64-27 • Fax: +49 06424 944 64-20 •