Numare Spectralab, Service Request Form:

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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 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 use the reverse side of this sheet to draw 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 First class US mail____, Priority US mail____, Federal     

    Express____,     Other:________________________________________________________

3. Twenty four (24) hour Express Service______.

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 ________________________

Required information:
    Please Note: If you are a currently associated with Numare Spectralab, 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:  Printed____________________________________________________
                                 Signature___________________________________________________