Acorn NMR Inc.
NMR Sample Submission Form

for use with GLP and GMP samples only

Print this form and enclose with your samples.     All requested information is required.

 

Date ________________  

Name ______________________   Phone _____________  email________________________

Company ___________________   FAX _________________    PO#  ______________

Data will be returned via US Mail.  If other shipment is preferred, please indicate: ______ 

To receive copies of NMR data via email, indicate:   FIDs     spectra

 GLP  if GLP, please indicate  FDA  EPA  (circle one)        

	In-Process inspection required?   Yes   No  (additional cost)

 GMP    

QA Review of data required?  Yes   No  (additional cost)

Protocol/Method ID & Rev. #: ____________________________ (if none, enter "None")

Sample ID __________________________________         Solvent ______________________

 (Note:  This is the identifier that will be used in reports and on spectra)

Sample storage (circle one):  Room temp  Refrig(approx 5C)  Freezer(-10 to -20C)  Dry ice

Work to be done (Circle all that apply)   1H   31P   13C   19F  D2O exch   Other ______

Sample to be (Circle one):       Returned     Discarded  

Indicate Hazards:  absorption  inhalation   smelly    reactive   special handling

Special requests: 

Sample ID __________________________________         Solvent ______________________

 (Note:  This is the identifier that will be used in reports and on spectra)

Sample storage (circle one):  Room temp  Refrig(approx 5C)  Freezer(-10 to -20C)  Dry ice

Work to be done (Circle all that apply)   1H   31P   13C   19F  D2O exch   Other ______

Sample to be (Circle one):       Returned     Discarded  

Indicate Hazards:  absorption  inhalation   smelly    reactive   special handling

Special requests: 

Acorn NMR Inc.          (925) 456-1020 		(925) 456-1024 FAX

7670 Las Positas Rd. 

Livermore, CA   94551        			 6/12/07