GxP NMR Sample Submission Form

Step 1: Fill out the form below.
Step 2: Click the SUBMIT button.
Step 3: Check your email for a PDF of the completed form.
Step 4: Print the PDF form and enclose it with your samples.
Step 5: Mail us your samples.

Date*

Name*

First Last

Phone Number*

FAX Number

Email*

A PDF will be emailed to you at this address that must be included with your sample submission.

Company*

PO#

Shipping

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

GLP or GMP?*

GLP
GMP

You have chosen GLP; please indicate*

FDA
EPA

In-Process inspection required?*

(additional costs applicable)

Yes
No

Protocol/Method ID & Rev. #:*

(if none, enter "None")

To receive copies of NMR data via email, indicate:

(you must have NMR processing software such as NUTS)

FIDs
spectra

Sample ID*

Solvent*

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

Sample Storage*

Room temp
Refrig (approx 5°C)
Freezer (-10 to -20°C)
Dry ice

Work to be done*

(Select all that apply)

¹H
³¹P
¹³C
¹⁹F
D₂O exch
Other

You selected Other*

Please enter additional requirements here.

Sample to be*

(Additional S&H charges are applicable)

Returned
Discarded

Indicate Hazards

absorption
inhalation
smelly
reactive
special handling

Notes:

Would you like to submit a second sample now?

Yes
No

Sample ID*

Solvent*

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

Sample Storage*

Room temp
Refrig (approx 5°C)
Freezer (-10 to -20°C)
Dry ice

Work to be done*

(Select all that apply)

¹H
³¹P
¹³C
¹⁹F
D₂O exch
Other

You selected Other*

Please enter additional requirements here.

Sample to be*

(Additional S&H charges are applicable)

Returned
Discarded

Indicate Hazards

absorption
inhalation
smelly
reactive
special handling

Notes:

Would you like to submit a third sample now?

Yes
No

Sample ID*

Solvent*

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

Sample Storage*

Room temp
Refrig (approx 5°C)
Freezer (-10 to -20°C)
Dry ice

Work to be done*

(Select all that apply)

¹H
³¹P
¹³C
¹⁹F
D₂O exch
Other

You selected Other*

Please enter additional requirements here.

Sample to be*

(Additional S&H charges are applicable)

Returned
Discarded

Indicate Hazards

absorption
inhalation
smelly
reactive
special handling

Notes:

Would you like to submit a fourth sample now?

Yes
No

Sample ID*

Solvent*

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

Sample Storage*

Room temp
Refrig (approx 5°C)
Freezer (-10 to -20°C)
Dry ice

Work to be done*

(Select all that apply)

¹H
³¹P
¹³C
¹⁹F
D₂O exch
Other

You selected Other*

Please enter additional requirements here.

Sample to be*

(Additional S&H charges are applicable)

Returned
Discarded

Indicate Hazards

absorption
inhalation
smelly
reactive
special handling

Notes:

Would you like to submit a fifth sample now?

Yes
No

Sample ID*

Solvent*

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

Sample Storage*

Room temp
Refrig (approx 5°C)
Freezer (-10 to -20°C)
Dry ice

Work to be done*

(Select all that apply)

¹H
³¹P
¹³C
¹⁹F
D₂O exch
Other

You selected Other*

Please enter additional requirements here.

Sample to be*

(Additional S&H charges are applicable)

Returned
Discarded

Indicate Hazards

absorption
inhalation
smelly
reactive
special handling

Notes:

Would you like to submit a sixth sample now?

Yes
No

Sample ID*

Solvent*

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

Sample Storage*

Room temp
Refrig (approx 5°C)
Freezer (-10 to -20°C)
Dry ice

Work to be done*

(Select all that apply)

¹H
³¹P
¹³C
¹⁹F
D₂O exch
Other

You selected Other*

Please enter additional requirements here.

Sample to be*

(Additional S&H charges are applicable)

Returned
Discarded

Indicate Hazards

absorption
inhalation
smelly
reactive
special handling

Notes:

Would you like to submit a seventh sample now?

Yes
No

Sample ID*

Solvent*

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

Sample Storage*

Room temp
Refrig (approx 5°C)
Freezer (-10 to -20°C)
Dry ice

Work to be done*

(Select all that apply)

¹H
³¹P
¹³C
¹⁹F
D₂O exch
Other

You selected Other*

Please enter additional requirements here.

Sample to be*

(Additional S&H charges are applicable)

Returned
Discarded

Indicate Hazards

absorption
inhalation
smelly
reactive
special handling

Notes:

Would you like to submit a eighth sample now?

Yes
No

Sample ID*

Solvent*

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

Sample Storage*

Room temp
Refrig (approx 5°C)
Freezer (-10 to -20°C)
Dry ice

Work to be done*

(Select all that apply)

¹H
³¹P
¹³C
¹⁹F
D₂O exch
Other

You selected Other*

Please enter additional requirements here.

Sample to be*

(Additional S&H charges are applicable)

Returned
Discarded

Indicate Hazards

absorption
inhalation
smelly
reactive
special handling

Notes:

Name

This field is for validation purposes and should be left unchanged.

Arrange in Advance

Because regulatory requirements vary, GMP work must be arranged in advance.

Please contact Acorn NMR to discuss your GMP needs.

Submission Forms

Shipping Information

Sample Requirements