Name*                            

E-Mail*

Your Campus Address*  

Campus Phone Extension*

Department*

Project/Grant Number (package costs)*

Shipping Account Number (e.g., Fed Ex Account)*

Principal Investigator                      

Preferred Ship Date*

Receiver's Name*

Receiving Institution Name*

Receiving Institution Address*

Receiving Institution Telephone Number*

Material to be shipped:

Chemical or Trade Name*

Quantity/Volume* (e.g., 100 ml, 10 lb., etc.)

Dimensions of Container* (More Info)

Monetary Value (for insurance/customs)*

Further Item Description:

Material Phase*      Gas      Liquid      Solid

Does the material to be shipped have any of the following characteristics?

Flammable (solid, liquid, gas)         
Poisonous/Toxic
Corrosive                                
Oxidizer                    
Spontaneously Combustible
Compressed gas                                
Radioactive   

Dry Ice         

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RADIOACTIVE MATERIAL SHIPMENTS
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If material is radioactive, which isotope(s)?  

What is the activity?    mCi     mCi

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PREFERRED SHIPPING COMPANY
===================================================

Please indicate your shipper preference:

Fed Ex    Yellow Freight  Other