Company/Client Acct. No.	Excipient/Raw Material API/DS/Intermediate Product (Non-Biologic) Nicotine Animal Health Non-Product Other (Explain) REQUIRED TO CHOOSE ONE	GMP Commercial (Lots Intended or On Market) GMP Commercial (Lot Not Intended for Market) GMP Non-Commercial GMP Non-Commercial Clinical GLP Non-GXP REQUIRED TO CHOOSE ONE
Third Party Submitter (if applicable)
Reporting Contact(s)
Quote #
PO #
ELLI Project Manager

Dispose of Sample- Yes	Hazardous-	BSL2- Blood Pathogen-

No Provide FedEx/UPS______________	Controlled Substance, Class-__________

**Please send an individual form for each material. Is this an additional sample? QL_____________

Sample Description (Please include hydration level) **Please note that each line item below will be considered an individual sample. Multiple containers to be tested individually should be separate line items.	No. Of Containers	Client ID # (if applicable)	Lot #	Requested Test(s)	Method Reference (e.g USP, EP, JP, LL Analysis#, Client Method, etc) Specification Document(include revision number)	Room Temp	Refrigerated	Frozen(-20C)	Frozen(-80C)	Protect from Light

**Any testing that is required for the compendia monographs will be performed and billed accordingly unless noted above. (Ex. Solution S, Specific Rotation, LOD)

Comments:

Client Signature/Date_____________________________

(REQUIRED)

Guidance Document for Sample Submission Form

To prevent delays, the following information must be included. If missing, testing will not be initiated until all information is supplied:

PO and Quote number. Failure to provide these will result in delays.

Sample description including hydration level, type, and/or nominal value or label claim, stability time point, condition, amount of sample submitted, etc.

Compendial tests requested with compendial designation and/or Non-compendial tests requested with method to be used.

Actual Specification Document(s) or Specification Reference(s) should be provided with each submission. If a version is not supplied the laboratory will use the most current version of the document located in our system.

Please submit separate containers for micro and chemistry testing. Contact your project manager if this is an issue.

Where compositing is indicated and multiple composites are needed, container identities must be indicated for each composite requested.

Signature and date (Can be hand written or electronically signed). Indicates approval with all applicable terms and conditions needed to initiate testing.

An SDS must be provided for all materials, if one is not on file samples will be placed on hold.

Indicate items such as but not limited to need for compositing, test by date, special instructions, etc. in the “Comments” box.

Prior to submission, email a copy of the completed form to your ELLI contact and send a copy with the samples.

If you are a new client contact, you must provide an address, phone number, and email address.

Disclaimers:

If expedited results are needed, call in advance for prior approval. This must be indicated in the comments section with the expected delivery date.

If storage condition is not identified, a condition similar to how the sample was received will be assigned.

If a requested test requires another value or analysis (e.g. Loss on Drying or water value) and the value is not provided nor the required test requested, ELLI will perform the necessary test(s).

If “USP/EP” or a similar notation is stated, ELLI will perform testing per both compendia unless otherwise stated.

If no contact information is provided for sample discard, samples will be discarded 15 days for water testing and 30 days for all other testing at no charge after the ELLI C of A is generated. (Note: If sample return is requested a FedEx or UPS account number must be supplied if not already on file).

If the measurement of uncertainty is required as per the ISO 17025 standard, then indicate in the comments section

Raw Materials Express Testing Requirements:

Testing is performed explicitly as per USP and/or EP without specification documents.

Outside of shipping box must be labeled as EXPRESS (or a special label must be applied).

Separate containers must be provided for micro and chemistry.

Sample paperwork must be received the day before samples arrive and must be emailed to your ELLI contact.

Addresses for shipment:

Lancaster, PA (USA): 2430 New Holland Pike, Suite C100, Lancaster, PA 17601

Clogherane Dungarvan Co. Waterford, Ireland (EU)

Portage, MI (USA): 6859 Quality Way, Portage, MI 49002