miRCURY™ microRNA Profiling Services
Sample Submission Form
Please complete this sample submission form and send it to for approval. Our scientists will review the form and contact you with instructions on how to ship your samples.

Project Title/Code

Title/Code

Your Contact Details

First Name:
Last Name:
Job Title:
Company/Institute:
Department:
Address Line 1:
Address Line 2:
Address Line 3:
City:
Zip/Postal Code:
Country: / State:
Phone: / Fax:
Mobile/Cell: / E-mail:

Invoice Details

(Please fill in name and billing address if different from above)

PO number:
VAT/TAX number*
Name:
Company/Institute:
Department:
Address Line 1:
Address Line 2:
Address Line 3:
City:
Zip/Postal Code:
Country: / State:
Phone: / Fax:
Mobile/Cell: / E-mail:

* EU only

Sample Description

Organism:
Tissue type:
Cell type:
Sample Type: / Total RNA? / miRNA enriched?
RNA Extraction method:
It is imperative that RNA is isolated using a method that preserves miRNA. We recommend the use of total RNA and not fractionated, miRNA enriched samples. For extraction of total RNA, we recommend to use the miRCURY™ RNA Isolations Kit – Cell & Plant or the miRCURY™ RNA Isolations Kit – Tissue. If RNA is extracted using phenol based methods (Trizol/TRI reagent or similar Phenol/GSCN based protocols), we recommend an additional cleaning of the samples, when the OD 260/230 ratios are lower than 1.7. Please use protocol in Appendix B, available in the Instruction Manuals for the two miRCURY™ RNA Isolation Kits.

Samples to be Submitted

Sample Number / Sample Name
(as it appears on vial) / Sample volume
(µl) / Concentration
(µg / µl) / OD
260/280 / OD
260/230
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19 / 21
20
21
22
23
24
25
26
27
28

Hybridizations to be Performed

Slide Number / Sample X (Hy3) / Sample Y (Hy5)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

Choice of Microarray Platform

Microarray platform / Select (X)
miRCURY LNA™microarray v. 11.0 (other species)
miRCURY LNA™ microarray v. 11.0 (hsa, mmu, rno)

.

Background and Purpose of Experiment

In order to perform the best possible service we invite you to provide us with information about the experiment and the type of information you expect to extract from it. Please enter all relevant details regarding the experimental set up which would influence the data analysis, i.e. please indicate which samples are replicates and which groups of samples you would like to compare. If you have special wishes for the statistical treatment and analysis of data please specify it below – this can avoid the need for additional data analysis after the receipt of the final report and save you precious time.

Confirmation

I hereby confirm that the samples I submit for analysis contain no biologically harmful organisms, or other biologically harmful components. Furthermore, I confirm that I have informed consent and permission to transfer samples to a third party (Exiqon) and have them analyzed.

Name (please PRINT)
Signature
Date

Shipping Instructions

Upon completion of this form, please send it to. Once our scientists have approved the form, you may ship your samples to the appropriate address listed below. Also please include a signed copy of the approved submission form in the package with your samples. We thank you for your interest in Exiqon’s miRCURY™ LNA Array microRNA Profiling Services and look forward to working with you.

Exiqon sample submission form – microRNA profiling services / Template version 5 / THE /14-Apr-2009Page 1 of 5

Outside North America
Exiqon A/S · Bygstubben 10

DK-2950 Vedbaek · Denmark

Phone: +45 45 660 888

North America

Exiqon Inc · 14F Gill Street
Woburn, MA01801 · United States

Phone: 1 (781) 376-4150

Exiqon sample submission form – microRNA profiling services / Template version 5 / THE /14-Apr-2009Page 1 of 5

Disclaimer

Customer obligations: Customer is responsible for the delivery of samples to Exiqon in such a manner as to maintain sample integrity, and in accordance with any relevant shipping and handling regulations or instructions. Customer will not provide any person-identifiable data to identify samples. By ordering, the Customer confirms to have acquired all the required ethical permissions and regulatory approval for the proposed work and Exiqon will have no liability if these permissions and approvals have not been properly granted. Customer will assure, to the best of their knowledge, that the sample is free of any substance, virus, bacteria etc. harmful to personnel. Customer agrees to indemnify Exiqon from all actions and liabilities resulted from Exiqon´s testing of any samples or the use of any data produced by Exiqon´s testing service. Customer will use the data provided by Exiqon for Research Use Only and NOT for any diagnostic purposes. Customer will not use data provided by Exiqon for commercial use or transfer data provided by Exiqon to third party for profit.

Exiqon obligations: On receipt of sample materials Exiqon will assess the suitability of the sample materials. If samples are considered to be of less than optimal standard, customer will be notified before proceeding. Exiqon will conduct the services according to their standard protocols for the type of sample provided and will provide Customer with data arising from the services as described. Exiqon guarantees storing of data and unused samples for a period of 90 days after delivery of the final report, unless specifically agreed otherwise. Exiqon will keep all information confidential and will not exploit data for any use other than general statistic purposes and troubleshooting. Orders may be changed or amended only by written agreement signed by both parties.

Additional stipulations: During the normal course of performing array hybridizations, some experiments may fail to produce usable data or test samples may accidentally be lost or damaged. Exiqon assumes no liability for the loss of customer samples or of microarrays during normal testing. Microarray results will vary depending among many things on the quality of the customer´s sample(s) and of the microarrays used for testing. Exiqon provides no warranty as to the quality of any data generated, and shall not be held liable for any damage or cost incurred from the use of such data.

Exiqon sample submission form – microRNA profiling services / Template version 5 / THE /14-Apr-2009Page 1 of 5