Client Information Company name Contact person, and address: phone and email: Billing Information IAS Quote No: Client PO # or AP Contact: Submission Information Date shipped: Shipper name and address (if not from client): Samples will be held for up to 3 months after analysis and disposed OF unless otherwise indicated. Please check here if samples are to be returned. Sample and Service Information Study No.: Service(s) Requested (To be performed by IAS R&D Division. Check all that apply.) Purity/Mass Verification Hepatocyte Stability Other Metabolism Formulation Microsomal Stability Method Development/Qualification Plasma Stability Metabolite ID Impurity Characterization Protein Binding CYP450 Assays- Inhibition or Phenotyping Other: Please specify for metabolism assays. Species Mouse Rat Monkey Human Dog Other: Incubation Conc. 1μm 5μm 10μm 20μm Other: Test Article/Compound(s) Submission: Please indicate amount of compound if provided (or NA, if previously provided) and if compound is in solution, the concentration and solvent (e.g. 5 mg/mL in DMSO). Powders are preferred; please check solvents that can be used with the powder. Please fill in compound information as completely as possible. Storage: Powders will be stored at room temperature and solutions will be stored at -20oC unless specified otherwise. Submission (see above for instructions) Monoisotopic Formula Salt Form Compound Name (Exact) Mass Weight Chemical Formula Amt (wt or vol) Conc. & Solvent Dissolution Solv. (as applicable) DMSO ACN MeOH H2O Structure provided below NA NA other: DMSO ACN MeOH H2O Structure provided below NA NA other: DMSO ACN MeOH H2O Structure provided below NA NA other: DMSO ACN MeOH H2O Structure provided below NA NA other: DMSO ACN MeOH H2O Structure provided below NA NA other: Describe the specific details of the service. Please provide storage instructions, characterization instructions, chemical structures, metabolite ID, presence of internal standard, plate maps, sample IDs…etc. here. For IAS Only: Log-in Date Initials Condition Location Log-in Date Initials Condition Location Log-out Date Initials Returned Disposed
Client Information Company name and address: Contact person, phone and email: Billing Information IAS Quote No: Client PO # or AP Contact: Submission Information Date shipped: Shipper name and address (if not from client): Samples will be held for up to 3 months after analysis and disposed OF unless otherwise indicated. Please check here if samples are to be returned. Sample and Service Information Study No.: Service(s) Requested (To be performed by IAS R&D Division. Check all that apply.) Purity/Mass Verification Hepatocyte Stability Other Metabolism Formulation Microsomal Stability Method Development/Qualification Plasma Stability Metabolite ID Impurity Characterization Protein Binding CYP450 Assays- Inhibition or Phenotyping Other: Please specify for metabolism assays. Species Mouse Rat Monkey Human Dog Other: Incubation Conc. 1μm 5μm 10μm 20μm Other: Test Article/Compound(s) Submission: Please indicate amount of compound if provided (or NA, if previously provided) and if compound is in solution, the concentration and solvent (e.g. 5 mg/mL in DMSO). Powders are preferred; please check solvents that can be used with the powder. Please fill in compound information as completely as possible. Storage: Powders will be stored at room temperature and solutions will be stored at -20oC unless specified otherwise. Compound Name Monoisotopic (Exact) Mass Salt Form (as applicable) Formula Weight Chemical Formula Submission (see above for instructions) Amt (wt or vol) Conc. & Solvent Dissolution Solv. Structure provided below NA NA DMSO ACN MeOH H2O other: Structure provided below NA NA DMSO ACN MeOH H2O other: Structure provided below NA NA DMSO ACN MeOH H2O other: Structure provided below NA NA DMSO ACN MeOH H2O other: Structure provided below NA NA DMSO ACN MeOH H2O other: Describe the specific details of the service. Please provide storage instructions, characterization instructions, chemical structures, metabolite ID, presence of internal standard, plate maps, sample IDs…etc. here. For IAS Only: Log-in Date Initials Condition Location Log-in Date Initials Condition Location Log-out Date Initials Returned Disposed
IAS-RD-General-Form-150612-Web_2017.docx