Request for Analytical Services

In order to initiate a service agreement, please fill out the following form. Please provide a purchase order number. International clients requesting analysis are required to submit payment in advance. We must receive this information prior to performing analysis of your sample(s).

We are required by our federal granting agencies to document publications resulting from our non-proprietary service activity. Should any of data we produce be used in a publication, please acknowledge our services and contact Dr. Parastoo Azadi at azadi@uga.edu for the appropriate grant number.

First Name *

Last Name *

Highest degree held

Position *

Department *

Institution *

Mailing Address

Street Address

Street Address Line 2

City *

States (Choose One) *

Postal Code *

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Phone Number *

Fax Number

Email *

Sample Information

Sample source

Animal

Plant

Bacterial

Fungi

Sample Name *

Analysis requested

Select all that apply. (Use shift + click to select more than one)

Other Analysis requested

Comments

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Payment Information

If payment of your analysis is to be made by purchase order, provide the PO# and billing address below.

PO#

Street Address

City

States (Choose One) *

Postal Code

Indicate if you would like instructions for a wire transfer.

Yes

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Source of Funding

The CCRC's analytical services are supported by funding from the US Department of Energy and the National Institutes of Health. We are required to document the funding information for this requested analytical service. Source of current or planned funding for the project: include the PI, agency/organization, grant/contract number, and annual direct costs.

PI First Name *

PI Last Name *

Granting Agency/Organization *

Grant/Contract Number *

Annual Direct Costs

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Published works

If you have published works (including "in press") and/or presentation abstracts that result from service activities, enter these below.

Provide full citation of publications and book chapters.

I agree to report published works that result from the CCRC's non-proprietary analytical services. *

Yes

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If you have trouble submitting this form, please contact Carol Connelly cconnelly@ccrc.uga.edu.