In order to help us prepare the highest quality Custom Pellets that precisely meet your needs and specifications we
require that you complete and submit a copy of this form with each order.
Please Attach Purchase Order Along With Shipping and Billing Addresses. Allow 4-6 weeks for delivery.
| PURCHASE ORDER NUMBER: _______________________________________________________________________________________ |
| INSTITUTION: _____________________________________________________________________________________________________ |
| INVESTIGATOR’S NAME:__________________________________________ E-MAIL ADDRESS:_________________________________ |
| TELEPHONE NUMBER: ___________________________________________ FAX NUMBER: _____________________________________ |
| COMPOUND NAME OR CODE NAME (no controlled substances accepted and should be clearly labeled for research purpose only): _________________________________________________________________________________________________________________ |
| IS THE ABOVE COMPOUND A CONTROLLED SUBSTANCE? YES NO |
| IS THE ABOVE COMPOUND LABELED FOR RESEARCH PURPOSE ONLY? YES NO |
| AMOUNT OF COMPOUND SHIPPED:_________________________________________________________________________________ |
| CHEMICAL IDENTITY/MOLECULAR WEIGHT: ________________________________________________________________________ |
| INTRINSIC SOLUBILITY: WATER, ALCOHOL, LIPID:____________________________________________________________________ |
| HEAT, COLD, LIGHT SENSITIVITY:___________________________________________________________________________________ |
| HALF-LIFE OF COMPOUND IN ANIMAL: _____________________________________________________________________________ |
| DESIRED BLOOD LEVELS :__________________________________________________________________________________________ |
| REQUIRED PELLET RELEASE TIME & DOSE PER PELLET:______________________________________________________________ |
| NUMBER OF PELLETS REQUESTED:_________________________________________________________________________________ |
| ANIMAL: GENDER, AVERAGE WEIGHT, AGE:_________________________________________________________________________ |
| TOXICITY:_________________________________________________________________________________________________________ |
| It is the responsibility of the investigator to provide all proteins, growth factors and peptides in a crystalline, powder or lyophilized form. IRA will be happy to provide, if necessary, a matrix stabilizer to increase the mass of the product. Due to residual loss in our multi-stage process, supply at least 50% more product than you request in pellet form. Please include your completed order form with Custom Pellet Information Form. |
| PHONE: | FAX: | INTERNET / E-MAIL: | ||||
| (941) 365-1406 | (941) 365-1703 | http://www.innovrsrch.com | ||||
| (941) 365-1506 | (941) 365-1803 | pellets@innovrsrch.com | ||||
| (800) 421-8171 (USA/Canada) | (800) 643-4345 (USA/Canada) | |||||
| (800) 648-6030 (USA/Canada) |