Sample submission form

Name:

Email:

Telephone:

Street Address 1:

Street Address 2:

Street Address 3:

Street Address 4:

Town / City:

State / Province / County:

Zip Code / Postal Code:

Country:

Invoice Street Address 1:

Invoice Street Address 2:

Invoice Street Address 3:

Invoice Street Address 4:

Invoice Town / City:

Invoice State / Province / County:

Invoice Zip Code / Postal Code:

Invoice Country:

Deposit type:

Sample 1: Full name of deposit

Sample 1: Deposit identification

Sample 1: Number of ampoules

Sample 1: Required Storage Temperature

Freezer (-80°C)
Liquid Nitrogen (-196°C)

Sample 1: GMO Category

Do you want to a second sample?

Yes
No

Sample 2: Full name of deposit

Sample 2: Deposit identification

Sample 2: Number of ampoules

Sample 2: Required Storage Temperature

Freezer (-80°C)
Liquid Nitrogen (-196°C)

Sample 2: GMO Category

Do you want to a third sample?

Yes
No

Sample 3: Full name of deposit

Sample 3: Deposit identification

Sample 3: Number of ampoules

Sample 3: Required Storage Temperature

Freezer (-80°C)
Liquid Nitrogen (-196°C)

Sample 3: GMO Category

Do you want to add a fourth sample?

Yes
No

Sample 4: Full name of deposit

Sample 4: Deposit identification

Sample 4: Number of ampoules

Sample 4: Required Storage Temperature

Freezer (-80°C)
Liquid Nitrogen (-196°C)

Sample 4: GMO Category

Do you want to add a fifth sample?

Yes
No

Sample 5: Full name of deposit

Sample 5: Deposit identification

Sample 5: Number of ampoules

Sample 5: Required Storage Temperature

Freezer (-80°C)
Liquid Nitrogen (-196°C)

Sample 5: GMO Category

Security Check:

Please Note:

The Culture Collections must receive full information regarding delivery at least 48 hours before dispatch. Failure to do so could result in your shipment being returned unopened to you. A Biohazard Risk Assessment Form must also be completed in order for your samples to be accepted. The Culture Collections is required to assess the GMO status of all deposits PRIOR to receipt. Therefore, we will contact all depositors to advise them when we can receive samples.

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