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:

Sample 1: Full name of deposit

Sample 1: Deposit identification

Sample 1: Number of ampoules

Sample 1: Required Storage Temperature

Liquid Nitrogen (-196°C)

Freezer (-80°C)

Freezer (-20°C)

Fridge (+4°C)

Sample 1: GMO Category

Do you want to deposit a second sample?

Yes

Sample 2: Full name of deposit

Sample 2: Deposit identification

Sample 2: Number of ampoules

Sample 2: Required Storage Temperature

Liquid Nitrogen (-196°C)

Freezer (-80°C)

Freezer (-20°C)

Fridge (+4°C)

Sample 2: GMO Category

Do you want to a third sample?

Yes

Sample 3: Full name of deposit

Sample 3: Deposit identification

Sample 3: Number of ampoules

Sample 3: Required Storage Temperature

Liquid Nitrogen (-196°C)

Freezer (-80°C)

Freezer (-20°C)

Fridge (+4°C)

Sample 3: GMO Category

Do you want to add a fourth sample?

Yes

Sample 4: Full name of deposit

Sample 4: Deposit identification

Sample 4: Number of ampoules

Sample 4: Required Storage Temperature

Liquid Nitrogen (-196°C)

Freezer (-80°C)

Freezer (-20°C)

Fridge (+4°C)

Sample 4: GMO Category

Do you want to add a fifth sample?

Yes

Sample 5: Full name of deposit

Sample 5: Deposit identification

Sample 5: Number of ampoules

Sample 5: Required Storage Temperature

Liquid Nitrogen (-196°C)

Freezer (-80°C)

Freezer (-20°C)

Fridge (+4°C)

Sample 5: GMO Category

Security Check:

Please Note:

Culture Collections will require confirmation of consent for any human primary tissue safe deposits from the depositor under The Human Tissue Authority (HTA) regulations. A copy of the Consent or Research Ethics Committee (REC) approval form must be supplied by the depositor with confirmation of REC expiry or review date.

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Human random controls

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Please Note: