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 Qnty of Sample submitted Storage Condition Is sample Toxic / Biological / Hormonal / Immunosuppressant? YesNo Test(S) to be carried out in details Limit MOA/STP/ Validation Report Pharmacopeial IPBPUSPPh.EurCHPJP Non-Pharmacopeial Provided By CustomerQbD Lab In-House Is mentioned MOA Validatedor Varified Is sample analysis to be performed with validation Results to be shared as Developmental Sample (Results for Information Only)Release Domestic Sample (Report on Form 39(Applicable to Indian FDA only))Regulatary Submission sample (Validation/varification compulsary to be done at QbD Lab Only) Attach Resume / Documents Remarks
