AssayGate, Inc. is pleased to offer testing services for protein biomarkers. Please complete the following information and return this form with your samples. Thank you! Study #Quote #PO #.Sample Shipping, Data Delivery And Billing InformationCompanySHIPPING CONTACTName First PhoneEmail Report ContactName First PhoneEmail Billing ContactBilling ContactBilling Address Street Address Billing Email Billing PhoneSample InformationSpecies Human Mouse Rat Non-human Primates Pig Other Specify Matrix Serum Plasma EDTA Heparin Other Specify Cell Culture Supernatant Urine Cell Lysate Tissue Homogenate Other Specify Storage Tube 0.5 - 0.65 ml 1.0 - 1.5 ml 1.7 - 2.0 ml Other Specify Other SpecifyOther SpecifyOther SpecifyVolume & Sample #μl/vialAliquot #Sample #Has Sample Manifest Been Submitted To Assaygate (orders@assaygate.com) By Email? Yes No Service Order & Sample Submission GuidelinesThe Service Order & Sample Submission Form must be completed to ensure the proper and expeditious processing of your samples. A printed copy of the completed form should be included with the sample shipment. Please provide the quote number, study number and PO number in the box at the top of the form which is a required field. Orders received without P.O. or Credit Card information will not be processed. If you are a new customer, please attach a copy of the purchase order to your sample submission form so we can ensure the billing information is correct. Credit card information is not retained. You must provide credit card information by phone for any orders you are charging on a credit card each time an order is placed. 1. SAMPLE VOLUME REQUIREMENTS: Volume requirements for your samples can be found in the AssayGate quote. 2. SAMPLE PACKAGING: 1). Make sure samples are in a tightly closed “LEAK-PROOF” tubes (e.g. RTT) or “LEAK- PROOF” aliquot tubes made of polypropylene. 2). Store a variety of vials and tubes with Storage Boxes, for use in ultra-low temperature freezers. 3). Pack samples with sufficient dry ice. Make sure your contents are frozen when you are ready to pack them. 4). Use an EPS foam container for its insulating properties, and place it inside a sturdy, corrugated cardboard box. As with storage containers, DO NOT seal your dry ice box airtight—the vapor needs to be able to escape or your package could explode. Go lightly with the packing tape. 3. SAMPLE SHIPPING AND DATA DELIVERY INFORMATION: Include the company name, telephone number, contact name and email address to where data should be sent and a contact name and email address to where sample inquiries should be addressed. Samples should be shipped on dry ice Monday thru Thursday via FedEx priority or other overnight delivery services to: James Lu AssayGate, Inc. 9607 Doctor Perry Road, Suite 101 Ijamsville, MD 21754 Phone 301-874-0988 Email orders@assaygate.com Fax 301-560-8288 Sample shipment date must be notified to AssayGate by email in advance or on the day when samples are shipped out5. SAMPLE MANIFEST: Sample manifest should contain unique sample accession numbers. Please identify your samples via electronic sample manifest, preferably in Excel format, and e-mail to orders@assaygate.com along with your sample submission form. When your samples are delivered, we verify the number of samples and labeled sample identifications against the submitted Sample Manifest. If there is a discrepancy, we will contact you. Samples will not be processed until all samples are properly identified. 4. SAMPLE INFORMATION: Indicate the species, sample type and, if plasma, the anticoagulant by checking the appropriate box, sample volume per vial, aliquot # per sample, storage tube size. Notes 1. This service order cannot be canceled once your submission form is submitted. 2. Sample leftovers will be kept in our freezers for 6 months and then destroyed unless otherwise requested by your email. 3. WE DO NOT SERVICE INFECTIOUS SAMPLES (BIOSAFETY LEVEL 3 & 4)! Order Date MM slash DD slash YYYY SignatureFOR ASSAYGATE STAFF USE ONLYDate Received:By:Shipping Conditions Acceptable Unacceptable Date Processed:Customer ID: First Assay Report Emailed/FAX’d On: