: Please provide the name of your
REPORT Recipient / Phone / Email
: Clearly indicate who should
receive the final report and any
relating to this project.
INVOICE Recipient / Email
: Clearly indicate who should
receive the invoice and any correspondence relating to payment information.
: Please indicate the site location
(city & state or city & country if outside the US).
: Please provide a valid Purchase
: Please indicate your primary
contact at Alcami.
Alcami Proposal #:
Please enter the Proposal Number
associated with your sample. The Proposal Number is an 8-character code in
: Enter the name of the sample
material as it should appear on the final report. For raw materials, please
reference the compendial name instead of the trade name.
Phase of Development
: Please select intended phase of
development for this material.
: Select the product form; describe
in the comments section as needed (e.g. white round HDPE bottle).
: Indicate if special controls that
may apply to the sample (e.g. protect from light).
: If the remaining sample is to be
returned, please provide us with shipping instructions. All shipping charges
will be invoiced at cost plus 10% unless a courier’s account number is
provided (e.g. FedEx, UPS, or DHL).
: Please indicate if the sample
material is a controlled substance. If Yes,
an NDC number and DEA Registration number.
a DEA Form 222 for any Schedule 1 or Schedule 2 compounds and include in the
Please ensure a
current DEA registration certificate on file with Alcami or include with the
each sample is properly labeled, including the concentration and the amount
of material submitted.
Copies of Raw Data
: Copies of raw data are available
: Please indicate if any special
hazards are associated with the sample(s) and describe in the Comment
refuse substances that it cannot handle safely or which lack sufficient
safety information for it to evaluate the risk to health or safety while in
All samples must
be appropriately labeled for the protection of office and laboratory
The carton must
clearly identify the potential hazard (for example: carcinogenic).
must include a Material Safety Data Sheet (MSDS) with the sample.
Turnaround Time (TAT):
Select Standard or Expedited as
submissions, please indicate the desired number of business days for
turnaround as stated in your Proposal / Quote.
Expedited turnaround times are subject to availability and terms of the
Expedited testing will incur
a surcharge as stated in the quote.
: Indicate clearly the lot number
that should be reported on the final report. Samples received without a lot
number will be entered as “N/A”.
Additional Sample Identification
: Briefly describe each sample as
needed for clear identification, e.g. Beginning / Middle / End, “In-Process”,
: Please indicate the product
strength of each sample.
Number of Containers
: Indicate the number of individual
containers included in the shipment.
Reporting Limits / Specification
: Please indicate the requested
reporting limits and specification document.
Results will be
reported by the method indicated. If no limit is provided, we will default to
associated compendia limits, or “Report Results” when compendial limits are
Please include a
copy of the approved, official specification. Please refrain from writing
limits or specifications on the form.
Sample Date / Time
: If applicable, supply the general
date and time sample was collected. Provide an attachment with details, if
Stability Time Point / Condition
: Please indicate the appropriate
time point / condition for each stability sample included in the submission.
Select the appropriate storage
condition for samples upon receipt at Alcami.
Test Descriptions / Test Procedures
: Indicate the Test Procedure code
(TP#) or name of each test required for the submitted samples, along with the
appropriate method reference for each.
Refer to the
Alcami Proposal / Quote for TP#s and test names.
Attach / include
additional documents as necessary (e.g. protocols, methods, etc.).
: Indicate the test(s) required for
each sample submitted.
: Use this section to document
: Please indicate the sample
destination as listed in the Alcami Proposal / Quote.
Click the Submit button to send the
completed form via e‐mail to Alcami.
Print & Sign the completed form
to include in sample shipment.
Shipping and Handling
Please include a completed Sample
Submission Form, along with MSDS, specifications, and any other relevant
correspondence with sample shipment. Please place all documents in an
envelope at the top of the box or affix to the outside of the box.
Pack samples appropriately to
prevent breakage and to ensure samples are protected from environmental
impact (heat, light, moisture) during shipment.
Please allow sufficient time for
international shipments to clear customs.