Solvias Order Form for Elemental Analysis and Microanalysis

Solvias AG
Sample & Order Management
Mattenstrasse 22
WRO-1055.3.34
P.O. Box
4002 Basel, Switzerland
Solvias Order Form
Name
Company
Address
ZIP City
State
Telephone Fax
E-Mail
Date
Analytical Method
(e.g. Ph. Eur., USP-NF, other...)
Internal Information
Date of receipt _________________
Contact
Tel. +41 61 686 65 00
Fax +41 61 686 63 15
E-mail orders@solvias.com
Purpose of Analysis
R&D analysis (non GxP)
for submission to regulatory authorities (data reviewing may be required)
release of investigational products (full validation of methods not required)
release of marketed products (typically requires validated method)
Attachments
Country
Signature
Order Description, Sample Designation, Acceptance Criteria
(Specifications), Additional Information, ...
Due Date*
Terms of Business of Solvias AG apply unless agreed otherwise in writing.
URGENT* EXPRESS*
Quotation Number
please continue on the next page, if appropriate
Referencing Information
(e.g. order no., reference no., project no., ...)
Billing Information
(e.g. purchase order no., cost center no, billing class. ...)
Different Billing Address (please specify on page 2)
Quality Standard
ISO 9001 (standard)
GMP
Scope
single determination
double determination
Sample
sample amount
number of samples
dispose of remaining sample(s)
return remaining sample(s)*
Storage Conditions
room temperature
5 ± 3 °C
≤ -15°C
≤ -60°C
protect from moisture
protect from light*
Hazard Information
no risks
unknown
cancero-, terato- or mutagenic
cytotoxic or hormone*
explosive*
narcotic substance*
Reporting
results only
analytical report
certificate of analysis (QA reviewed)*
Archiving
keep raw data at Solvias
submit raw data to customer*
submit copy of raw data to customer*
*(surcharges may apply, see pricelist)
Order-No. _________________ Date of closing _________________
2008-12

Solvias AG
Sample & Order Management
Mattenstrasse 22
WRO-1055.3.34
P.O. Box
4002 Basel, Switzerland
Solvias Order Form
Contact
Tel. +41 61 686 65 00
Fax +41 61 686 63 15
E-mail orders@solvias.com
Order Description, Sample Designation, Acceptance Criteria (Specifications), Additional Information, ...
Billing Address (use only if different from shipping address as specified on page 1)
Name
Company
Address
ZIP City
State
Telephone Fax
E-Mail
Country
Terms of Business of Solvias AG apply unless agreed otherwise in writing.
2008-12