Sample Submission Form (SSF)


PLEASE NOTE:  ONLY ONE MATERIAL PER FORM

*Entry required for submission

General Instructions (detailed instructions on page 2)

1.       Fill out the form completely. Missing information may delay testing.

2.       Submit the form via email – follow prompts after choosing sample destination.

3.       Print and include the submitted form in your sample shipment along with current Specification Document(s) and Safety Data Sheet (SDS).

 

I. Contact Information

* Company Name:

PO#

* REPORT Recipient:

* INVOICE Recipient

Alcami Primary Contact:

* REPORT Email:

* INVOICE Email:

* Alcami Proposal #:

REPORT Phone:

Billing Location:

 

II. Sample Information

* Material Name:

* Phase of Development:

* Product Form:

* Special Handling?

* Sample Disposition:

Return Shipping Account #:
(Provide instructions in Comments)

* Controlled Substance?

If Yes, DEA Registration #:

If Yes, NDC #:

* Copies of Raw Data Required?

*Hazardous Material?

* Turnaround Time (TAT)

Expedited TAT (Business Days):

(Subject to availability; discuss with your project manager)

Test Descriptions / Test Procedures (TP)
(Include Method Reference for Each)

Lot Number

Additional Sample Identification

Sample Strength

# of Containers

Amt. per Container

Reporting Limits / Specification

Sample Date / Time (Water samples, etc.)

Stability Time Point / Condition

Sample Storage

Testing Matrix: Check the boxes below for tests to be applied to each sample.

 

Comments (Other Product Forms or Special Handling Requirements, Sample Return Instructions, etc.)

Please answer this security question. What is the sum of 4 + 5?

*Signature:
(indicates approval with all applicable terms & conditions)

Date
[dd-mm-yyyy format]:

* Sample Destination:






02JULY2019

 


 

Sample Submission Instructions

       Fill out the form completely, including product name, lot number(s), required test(s) and methods, and the number of samples sent.

       Please submit only one material type to be tested per form.  Multiple samples of the same material may be included on a single form.

       All sample containers must be appropriately labeled for the protection of office and laboratory personnel.

       Incomplete information may cause delays

Contact Information

a)   Company Name : Please provide the name of your company.

b)  REPORT Recipient / Phone / Email : Clearly indicate who should receive the final report and any

correspondence relating to this project.

c)   INVOICE Recipient / Email : Clearly indicate who should receive the invoice and any correspondence relating to payment information.

d)  Site Location : Please indicate the site location (city & state or city & country if outside the US).

e)  PO # :  Please provide a valid Purchase Order number.

f)   Alcami Representative : Please indicate your primary contact at Alcami.

g)   Alcami Proposal #: Please enter the Proposal Number associated with your sample.  The Proposal Number is an 8-character code in ABCD1234 format.

Sample Information

a)     Material Name : 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.

b)     Phase of Development : Please select intended phase of development for this material.

c)     Product Form : Select the product form; describe in the comments section as needed (e.g. white round HDPE bottle).

d)     Special Handling : Indicate if special controls that may apply to the sample (e.g. protect from light).

e)     Sample Disposition : 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).

f)      Controlled Substances :  Please indicate if the sample material is a controlled substance. If Yes,

1.         Please include an NDC number and DEA Registration number.

2.         Please complete a DEA Form 222 for any Schedule 1 or Schedule 2 compounds and include in the sample shipment.

3.         Please ensure a current DEA registration certificate on file with Alcami or include with the sample.

4.         Please ensure each sample is properly labeled, including the concentration and the amount of material submitted.

g)     Copies of Raw Data : Copies of raw data are available upon request.

h)     Hazardous Material : Please indicate if any special hazards are associated with the sample(s) and describe in the Comment section.

1.         Alcami may 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 its possession.

2.         All samples must be appropriately labeled for the protection of office and laboratory personnel.

3.         The carton must clearly identify the potential hazard (for example: carcinogenic).

4.         All shipments must include a Material Safety Data Sheet (MSDS) with the sample.

i)      Turnaround Time (TAT): Select Standard or Expedited as appropriate.

1.         For Expedited submissions, please indicate the desired number of business days for turnaround as stated in your Proposal / Quote.

2.         Requested Expedited turnaround times are subject to availability and terms of the quote.

Expedited testing will incur a surcharge as stated in the quote.

j)      Lot Number : 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”.

k)     Additional Sample Identification : Briefly describe each sample as needed for clear identification, e.g. Beginning / Middle / End, “In-Process”, “Stability”, etc.

l)      Sample Strength : Please indicate the product strength of each sample.

m)   Number of Containers : Indicate the number of individual containers included in the shipment.

n)     Reporting Limits / Specification : Please indicate the requested reporting limits and specification document.

1.         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 not available.

2.         Please include a copy of the approved, official specification. Please refrain from writing limits or specifications on the form.

o)     Sample Date / Time : If applicable, supply the general date and time sample was collected. Provide an attachment with details, if necessary.

p)     Stability Time Point / Condition :  Please indicate the appropriate time point / condition for each stability sample included in the submission.

q)     Sample Storage: Select the appropriate storage condition for samples upon receipt at Alcami.

r)      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.

1.         Refer to the Alcami Proposal / Quote for TP#s and test names.

2.         Attach / include additional documents as necessary (e.g. protocols, methods, etc.).

s)      Testing Matrix : Indicate the test(s) required for each sample submitted.

t)      Comments : Use this section to document additional information.

u)     Sample Destination : Please indicate the sample destination as listed in the Alcami Proposal / Quote.

Form Submission

a)     Click the Submit button to send the completed form via e‐mail to Alcami.

b)     Print & Sign the completed form to include in sample shipment.

Shipping and Handling

a)     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.

b)     Pack samples appropriately to prevent breakage and to ensure samples are protected from environmental impact (heat, light, moisture) during shipment.

c)     Please allow sufficient time for international shipments to clear customs.

Please Use the Following Shipping Addresses for Samples:

Durham, NC:

Alcami Corporation

Attn: SCU

4620 Creekstone Drive

#200

Durham, NC 27703

Edison, NJ:

Alcami Corporation

Attn: SCU

165 Fieldcrest Avenue

Edison, NJ 08837

St. Louis, MO:

Alcami Corporation

Attn: SCU

4260 Forest Park

Avenue, Suite 201

St. Louis, MO 63108

Wilmington, NC:

Alcami Corporation

Attn: Tech Center

Sample Receipt

2320 Scientific Park Drive

Wilmington, NC 28405

Weert, Netherlands:

Alcami Corporation

Solid State Analytics

Vliesvenweg 1

6002 NM Weert, Netherlands