IICH QUOTATION REQUEST FORM

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NAME: __________________________________________________

COMPANY: _______________________________________________

TEL: ______________________________________

FAX: ______________________________________

E-MAIL: ______________________________________

Name of Compound and Position of label: _______________________________________

___________________________________________________________________________

CODE: _____________________________________________________________________

Amount:  ___________________________________________________________________

Specific Activity: ____________________________________________________________

Radiochemical Purity: ________________ 

Chemical Purity: _____________________

Formulation (neat; solution; solvent desired): ______________________________________

Expected date of delivery: ______________________________________________________

Structural Formula:
 
 
 
 
 
 

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Signature:                                                                                               Date: