Custom Pellet Information Form


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.

INNOVATIVE RESEARCH OF AMERICA CONTACT INFORMATION:
2 NORTH TAMIAMI TRAIL, SUITE 404
SARASOTA, FLORIDA 34236 USA

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)