Custom Media Request

First Name *

Last Name *

Customer Number

Company/Institution *

Street Address *

Address Line 2

City *

State *

Zip Code *

Email Address *

Phone Number *

Media Name *

Media Format *

Solid media, 100 mm agar plates, 4 plates per pack, minimum order is 45 packs.

Liquid media, 5 mL in Hungate capped tubes, 10 tubes per pack, minimum order is 40 packs.

Liquid media, 500 mL in bottles, minimum order is 5 bottles.

Liquid media, 250 ml bottles, minimum order is 10 bottles

Other Other

pH *

7.2 +/- 0.5

Other Other

Provide a brief description of the media application
(e.g. isolation, enrichment, preservation, all bacteria, specific bacteria). *

AS-Number *

Quantity

Price, Custom pack

Quote#

Additional items, one time set fees.

AS-COF, Manufacturing documentation (One time labor rate), $100

AS-COA, Certificate of analysis, $75

AS-CPI, Custom product insert, $75

AS-MSDS, Material Safety Data Sheet, $350

AS-SLD, Shelf-life determination (3 lots, real time), $250

AS-BACT, Purchase additional non-stock bacteria, List price

AS-RMA, Raw material acquisition, list price

Quantity of additional items.

	AS-CMD, Advanced Custom Media Design, $125/hour
	AS-BACT, Additional bacteria for performance testing, $25 each (in stock)

Current Total:

$0.00

Manufacturing Record:

Media Formulation and Policies: *

Quote: *

Send the quote to:

Customer

Customer Service

Anaerobe Systems 15906 Concord Circle Morgan Hill, CA 95037

customerservice@anaerobesystems.com www.anaerobesystems.com
phone: 1-800-443-3108 fax: 408-782-3031

Doc# CS-2006b Rev 0