*Company:

*Contact:

*Address:

Address:

*City:

*State/Province: Select One Alabama Alaska Alberta Arizona Arkansas Armed Forces - AA Armed Forces - AE Armed Forces - AP British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada Newfoundland New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Not Listed

*Postal Code:

Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia Botswana Bouvet Island Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire (Ivory Coast) Cuba Cyprus Czech Republic Denmark Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malaysia Mali Malta Marshall Islands Martinique Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and The Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa S. Georgia and S. Sandwich Isls Spain Sri Lanka St. Helena Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Tunisia Turkey Turkmenistan Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands (British) Virgin Islands (US) Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe

*E-mail:

Telephone:

Fax:

  Customer sending materials for service only

  EP provides materials

Part Number:
(If known) 

*Description:

*Quantity:

Sales Rep:

Process Required or Requested*

Some options not available for all container types

  Depyrogenation, validated 3-log reduction

  Surface treatment (silanization)

  Surface treatment (siliconization)

  TOC process

  Particulate cleaning

  Irradiation

  Sterile foil-wrap process

  WFI rinse (Containers< 250 mL)

  USP purified rinse (containers > 250 mL)

  Autoclave

  RNase/DNase Processing

  Other

  Individual unit

  Multi-unit

  Single

  Double

  Autoclave bag in cleanroom bag (closures only)

  Autoclave bag (single, double, triple)

  Autoclave wrap x 2

  Foil-wrap #:  

  Clean polypropylene tray-pack: Shrink-wrapped with double bag; standard

 Other packaging configurations (describe):

 

  C of A: TOC

  Certificate of Processing

  C of Sterility/USP

  C of A: Endotoxin

  C of A: Particles

  C of A: RNase/DNase

  Materials Certificate of Compliance (only if EP provides materials)

  Selected testing by USP Methods

 Other tests or special documentation (describe):

 

Method of shipment will be pre-paid collect, UPS ground or Yellow Freight, unless specified.
Please record your preferred shipper and collect shipping number if other.

Shipping:

 

Minimum lead-time for custom product is dependent upon quantity, analytical requirements,
and availability of materials. Custom Cleaning Specification Sheet must be signed and dated. Failure to do so may cause your quote to be delayed. All information exhcanged between "EP Scientific" and the above "Company" is considered confidential. EP will not be responsible for failure by the customer to request any other requirements not included on this sheet.

Date:

 

Purchase Order: