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Custom products >

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Custom Product Request

Salutation:

First name:*

Last name:*

Title:

Company:*

Address:*

City:*

State:*

Zip/postal code:*

Country:*

Email address:*

Phone number:*

Date needed:

Product requested:*

Fresh or Frozen?

Fresh Frozen

Format

# of Vials

# Cells/ Vial

6-well plate collagen coated

12-well plate collagen coated

24-well plate collagen coated

48-well plate collagen coated

96-well plate collagen coated

12.5-cm² T-Flask collagen coated

75-cm² T-Flask collagen coated

175-cm² T-Flask collagen coated

Suspension (minimum qty 10 million cells)

Other

	Specialized Medium	Insert recipe for specialized medium here:
	Other
	select amount required
	Medium Size	Quantity
	250 mL bottle
	500 mL bottle
	1 L bottle
	Other
Please provide additional information on medium product specifications below (i.e. sterility, endotoxin, testing, pH, etc.).
Additional Information:

Tissue will need to be acquired?

IVT to acquire tissue Customer will provide tissue Other

What Species?

Single male

	Age Requirements	Yes No
	Medical Requirements	Yes No
Other requirements			(specify)

Single female

	Age Requirements	Yes No
	Medical Requirements	Yes No
Other requirements

Male pool

	Quantity
	Age Requirements	Yes No
	Medical Requirements	Yes No
Other requirements

Female pool

	Quantity
	Age Requirements	Yes No
	Medical Requirements	Yes No
Other requirements

Mixed gender pool

	Quantity	males: females:
	Age Requirements	Yes No
	Medical Requirements	Yes No
Other requirements

Single male
Single female
Male pool	quantity:
Female pool	quantity:
Mixed gender pool	quantity males:	females:
	other specifications:

Below is a list of custom product specifications. In producing your product, what items must be considered for your custom request?

Provide specific product testing or product qualification