Customized Request

Customized Request

Name of Product: / To be filled in by Capricorn Scientific
Cat. 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 •