1. Sample identification:

2. Sample weight in milligrams:

3. Sample purity: Pure; Mixture.
    If mixture, estimated number of components:    

    If mixture, estimated mole fraction of principal component:

4. Sample molecular weight:, Known or Estimated

5. What deuterated solvent or solvent mixture should be used?

    What reference compound should be used?       

6. For hazardous samples, briefly describe hazard(s) and note appropriate precautions:

7. Check the correct choice(s) regarding the sample's stability: A. Stable. B. Unstable if
    exposed to: Air, Moisture, Light, High Temperature. Other,, explain:

8. Completed samples will be disposed of by environmentally accepted GLP/GMP methods unless directed otherwise.
    Return to sender , Return to address listed below:

9. Please include structural formula(e) of all relevant structures. This information is to be
    used only for the purpose of determining whether or not the sample under investigation contains
    the expected component(s). This information is protected by strict confidentiality even in the
    absence of formal confidentiality agreements between our mutual companies.

Experimental Information:

1. List the types of NMR experiments to be performed on sample. Include experimental conditions.    

2. Results are to be returned by FAX, First class US mail, Priority US mail, Federal Express,     

    Other:

3. Twenty four (24) hour Express Service. (Twelve and One Half dollars ($12.50) per hour surcharge.)

Requestor Information: Complete all applicable sections below:

Optional information:

1. Shipping address if different than billing address:    
    Name:           

    Company:      

    Mail Stop:        Street:     

    Town:        

    State:     , Zip Code:

2. FAX phone number with area code:

Required information:
    Please Note: If you are a current NSI customer, you can skip items 1, 2, and 3.

1. Billing address:     

        Company:

        Accounts payable representative

        Street:            

    Town:, State: , Zip code:
2. Accounts payable phone number w/ area code & ext.

3. Your phone number w/ area code & ext.

4. Purchase order number and/or account number

5. Service request date:    

6. Requestor's name:          

7. Requestor's e-mail address (required):          

    Note: Please submit signed copy with sample submission.