Request Form SAMPLE REQUEST FORM Date of Sample Dispatch Customer Name Address Email Phone QbD Quotation No. P.O. No. Name of the Sample Label Claim (If any) Mfg. Date Batch No. / Lot No. Exp. Date Name of the Manufacturer Mfg. Lic. No. Quantity of Sample Submitted Storage Condition Is sample Toxic / Biological / Hormonal / Immunosuppressant? YesNo Test(s) to be carried out in detail Limit MOA / STP / Validation Report Pharmacopeia IPBPUSPPh.EurCHPJP Non-Pharmacopeial Provided By CustomerQbD Lab In-House Is the mentioned MOA ValidatedVerified Is the sample analysis to be performed with validation? YesNo Results to be shared as Developmental Sample (Results for Information Only)Release Domestic Sample (Report on Form 39 (Applicable to Indian FDA only))For Regulatory batch release (validation/verification/tech transfer must be done at QbD only) Attach Documents Remarks
