* Marked fields are mandatory

Customer Reference No.& Date :
Sample Particulars : (Please provide accurate and legible information)
Sl.No. *Sample Name Application No.(ANDA/NDA etc.) Code/Batch No. Mfg.Dt. Exp.Dt. Manufactured By B.Size *Qty.Sub. *Test Required *Standard *Spec. *Purpose

S.No. Please Provide the Following Information Remark
1 The purpose of testing is as indicated above:

(1) For cGMP purpose(Sample No.2)

(2) For R & D / internal purpose(Sample No.1)

Any Other

2 Do you want the method submitted by you to be validated for its suitability (charges may apply)?
3 Is the reference standard or device submitted by you traceable? Please send relevant certificate or document alongwith the sample. (Where applicable)
4 Please provide details of any other material supplied by you
5 Any precautions to be taken while handling the sample / supplied item (Including storage)?

I hereby declare that the above sample (s) are submitted with the knowledge and consent of my company. I accept the terms of Sipra Labs Limited. View Terms & Conditions