Study Initiation Form (2011) :: Applied Genetics Laboratories, Inc.

COMPLETE ONE FORM FOR EACH CELL LINE SUBMITTED. If information is missing, your cells will be held without further manipulation, and you will be contacted to correct the problem. Normal turnaround time for our standard cytogenetics services is 4-6 weeks. PLEASE CONTACT US AT (800)235-5529 or agl@appliedgenetics.com TO SCHEDULE YOUR TESTING.

* indicates required field
Method of Payment *
Cell Line Designation *
Write the cell line ID EXACTLY as you wish it to appear in the final report.
Analysis Requested: * Isoenzyme (Species Identification) Cytogenetics (Karyotypes/Aberration Analysis/Chromosome Count) Both
Growth Characteristics: * Monolayer Suspension Bi-phasic

Growth Conditions: (Standard growth conditions are 37±1℃ and 5±1% CO₂ in stationary flasks.)

Temp (℃) *

% CO₂ *

Stationary or Shaker *
If shaker, please give RPM.

Species
(optional)
***BIOSAFETY LEVEL: * Level 1: Cells of non-primate origin (e.g., mouse) that do not harbor a primate virus and are not contaminated with bacteria, mycoplasma, or fungi. Level 2: All primate and unidentified cells. Also, all cells exposed to or transformed by a primate virus or contaminated with bacteria, mycoplasma, or fungi. Cells normally considered Level 2 but that have been tested and are free of viruses, bacteria, mycoplasma, and fungi are treated as Level 1.
RUSH STATUS: * Yes No
(inquire about availability)
An additional service charge applies for Level 2 and for rush status.
Doubling Time *
Splitting Ratio *
Media Changes *
Other Comments

Please address all reports to:
Name *
Company *
Address Line 1 *
Address Line 2
City, State, Zip *
Country *
Phone *

Please address the billing to:
Billing Name *
Billing Company *
Billing Address Line 1 *
Billing Address Line 2
Billing City, State, Zip *
Billing Country *
Billing Phone *

Contact Information:
Contact Name *
Contact Email *

Contact Phone *
Contact Fax *

Upon successful submission of this form, a confirmation will be sent to the email address provided. Please contact AGL at (800)235-5529 or agl@appliedgenetics.com to schedule your testing.