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Sl No.

Sample Name *

Application No.(ANDA/NDA Cft. if available)

Code/Batch No.

Mfd.Dt.

Exp.Dt.

Manufactured By

B.Size

Qty.Sub.

Test Required

Standard

Spec.

Purpose

Action

Special instruction if any:(e.g. Material safety, Sample return etc.)

S.No.	Please Provide the Following Information	Remark
1	The purpose of testing is as indicated above:	(1) For cGMP purpose()	(2) For R & D / internal purpose()	Any Other
2	Do you want the method submitted by you to be validated for its suitability (charges may apply)?	Yes No
3	Is the reference standard or device submitted by you traceable? Please send relevant certificate or document alongwith the sample. (Where applicable)	Yes No NA
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)?	Yes No

Test report delivery mode :

Self Courier Other

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

Submitted By :

ERF No. XXXX