Request for Processing Form

Tell us a bit about you and your company:

Company Name*

Contact Name*

First NameLast Name

Contact Email*

example@example.com

Contact Phone Number*

Area CodePhone Number

What is your preferred method of payment for this run?*

Credit CardNet 30 (ONLY select this is you have already completed a Credit Application and have been approved for Net 30 terms)

Which email address should we send the invoice to?

example@example.com

PO Number

Please upload a copy of the PO

Great! Now let's talk about how we're going to process the samples.

What date do you expect the samples to arrive at E-BEAM?

Do you have any additional shipping notes?

Example: product needs to be shipped with ice packs, split shipment, etc.

Please send return shipping labels for the product (either in the box or emailed to your Tech Services rep). NOTE: FedEx Ground is not accepted. Please select "yes" below to acknowledge.*

YesNo

You can upload your shipping label here, include it in the box, or email it to your Tech Services rep. NOTE: If you do not provide a label beforehand, it will delay the return shipping process.

Do you have any special handling requests?

Example: product needs to be kept frozen, product must remain upright, etc.

What type of run is this? (If you're not sure, this should be listed on your quote.)*

Please click "Yes" to acknowledge the following statement. After Dose Mapping is complete on both accelerators, EBS will dispose of the material used for dose mapping. Dose mapped material is processed numerous times, exceeding the max dose of the product. EBS also breaks the sterile barrier to place dosimeters for dose mapping. The material is not sellable and is not sterile.*

YesNo

How many different doses are you requesting?*

What is the first dose requested?*

How many samples need to be processed at that dose?*

Please indicate the number of samples to be handled by E-BEAM. For example, if you are sending 1 bag of 20 pieces but you want us to take the pieces out of the bag for processing, then please indicate "20."

What are the units for the samples?*

PiecesBagsBoxesOther

What is the product code for the samples? If none, please put N/A*

NOTE: The product code MUST be listed on either the product or the box/bag holding the product.

What is the lot number for the samples? If none, please put N/A*

NOTE: The lot number MUST be listed on either the product or the box/bag holding the product.

What is the product description? If none, please put N/A*

This will be listed on your Certificate of Irradiation along with the product code and lot number.

What is the second dose requested?*

How many samples need to be processed at that dose?*

Please indicate the number of samples to be handled by E-BEAM. For example, if you are sending 1 bag of 20 pieces but you want us to take the pieces out of the bag for processing, then please indicate "20."

What are the units for the samples?*

PiecesBagsBoxesOther

What is the product code for the samples? If none, please put N/A*

NOTE: The product code MUST be listed on either the product or the box/bag holding the product.

What is the lot number for the samples? If none, please put N/A*

NOTE: The lot number MUST be listed on either the product or the box/bag holding the product.

What is the product description? If none, please put N/A*

This will be listed on your Certificate of Irradiation along with the product code and lot number.

What is the third dose requested?*

How many samples need to be processed at that dose?*

Please indicate the number of samples to be handled by E-BEAM. For example, if you are sending 1 bag of 20 pieces but you want us to take the pieces out of the bag for processing, then please indicate "20."

What are the units for the samples?*

PiecesBagsBoxesOther

What is the product code for the samples? If none, please put N/A*

NOTE: The product code MUST be listed on either the product or the box/bag holding the product.

What is the lot number for the samples? If none, please put N/A*

NOTE: The lot number MUST be listed on either the product or the box/bag holding the product.

What is the product description? If none, please put N/A*

This will be listed on your Certificate of Irradiation along with the product code and lot number.

What is the fourth dose requested?*

How many samples need to be processed at that dose?*

Please indicate the number of samples to be handled by E-BEAM. For example, if you are sending 1 bag of 20 pieces but you want us to take the pieces out of the bag for processing, then please indicate "20."

What are the units for the samples?*

PiecesBagsBoxesOther

What is the product code for the samples? If none, please put N/A*

NOTE: The product code MUST be listed on either the product or the box/bag holding the product.

What is the lot number for the samples? If none, please put N/A*

NOTE: The lot number MUST be listed on either the product or the box/bag holding the product.

What is the product description? If none, please put N/A*

This will be listed on your Certificate of Irradiation along with the product code and lot number.

Please describe what you want to process. Include the number of pieces per requested dose, product code, lot number, and product description, if applicable.*

What is the requested dose range? (min - max internal dose)*

If you're not sure, talk to your Tech Services rep!

What is the product code?*

What is the lot number?*

What is the product description?*

How many boxes of product are you sending?*

What is the requested sublethal dose?*

If you're not sure, talk to your Tech Services rep!

What is the product code?*

What is the lot number?*

What is the product description?*

How many samples are you sending?*

What are the units for the samples?*

PiecesBagsBoxesOther

Is there anything else we need to know?

E-BEAM Services, Inc.