PLEASE PRINT THIS FORM TO YOUR LASER PRINTER AND INCLUDE WITH YOUR SAMPLE(S)
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______. (Twenty dollars ($20.00) 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 ________________________
Required information:
Please Note: If you are a current Numare Spectralab 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: Printed____________________________________________________
Signature___________________________________________________
Please ship samples to the address below:
Numare Spectralab
Attention: Lawrence Byrnes
3551 Winding Road, Hidden Meadow Farm
Kintnersville, PA, 18930-9543