Sample Submission Form for Mac

							                                                                                                                                                                                                       Asuragen
                                                                                                                                                                                               Confidential and Proprietary
                                                                                                                                                                                              SOP 7.5.4-4, Attachment 2 R9
                                                                                                                                                                                               Sample Submission Form




Service Request Form                    Asuragen Services -- Nucleic Acid Isolation, Expression Profiling, and Bioinformatics

                                                                      email to:        serviceorders@asuragen.com

Customer Name                                                                                      Services                               Platforms
Phone (Optional)                                                                                     RNA Isolation                            Affymetrix Gene Expression Array
                                                                                                                                              Illumina BeadArray
                                                                                  Check all that




Email Address (Optional)                                                                             DNA Isolation
                                                                                                                                              ABI TaqMan
                                                                                     apply:




Date Submitted                                                                                       mRNA Profiling                           Agilent Microarray
                                                                                                     microRNA Profiling                       Affymetrix SNP Array 6.0
Job # (or Quote #)
                                                                                                                                              Affymetrix GeneChip miRNA Array
Sample Storage Solution


Title of Experiment
                                                                                                     Custom:


Sample Information                                                                     Experimental Factors and Levels
                                    Customer-Provided RNA/DNA or
                                          Tissue/Cell Data                                                       Factor 1 Name:       Factor 2 Name:       Factor 3 Name:
                                                                         OD
Customer's Tube Name or                                                                                                                                                          Comments
                                  Mass (ng for      Volume (µL for     Reading           Tissue/Cell Type        _____________        _____________        _____________
       Identifier                                                                                                                                                                (Optional)
                                RNA/DNA; mg for      RNA/DNA; mL      (Optional)                                (Enter Levels for    (Enter Levels for    (Enter Levels for
                                 Tissue; or Total   for Tissue/Cell                                            Each Factor Below)   Each Factor Below)   Each Factor Below)
                                   Cell Count)          Lysate)




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          Effective Date: 08Apr10