Gene Expression Analysis Service
Sample Submission Form
PHONE
FAX
WEB SITE
(888) 528-8818
(713) 664-8181
www.lcsciences.com
Please complete this form and email to us (orders@lcsciences.com) prior to sending your samples.
[Part 1 – Contact Information]
Shipping Information
Billing Information
Name:
Name:
Institution:
Institution:
Department:
Department:
Address 1:
Address 1:
Address 2:
Address 2:
City:
City:
State:
State:
Zip:
Zip:
Country:
Country:
Phone:
Phone:
FAX:
FAX:
Email:
Email:
[Part 2 – Payment Information]
Quote Number:
Payment Method:
Purchase Order Number
Credit Card
PO Number:
Credit Card Number:
PO Amount:
Card Type:
Expiration Date:
Name on Card:
[Part 3 – Sample/Array Information]
Sample
Number
Sample Name
Sample Type
Sample Source
(Total RNA,
mRNA, cells, etc.)
(Tissue or Cell
Line)
Array Part
Number
Extraction
Method (if
applies)
1
2
3
4
5
6
7
8
9
10
© 2011 LC Sciences LLC CF-30-07B
Sample
Solution
Quantity
(µg)
Conc.
(µg/µl)
Amplification
Required
[Part 4 – Data Analysis Request Information]
In the space below please describe, in general terms, the comparisons you would like to make.
1.
Test Type: select t-Test or ANOVA
2.
Test No.: use sequential number, such as t-Test-01, t-Test-02, etc.
3.
Test Name: use a short and proper name, such as wt vs mutant
4.
Group No.: use 1 and 2 to define the two groups of samples to be compared in t-Test; use sequential number in ANOVA
5.
Group Name: use short and proper names, such as control, wildtype, mutant, etc.
6.
Sample Name: select a sample name from your list of samples.
7.
Pairing: if a paired t-Test is required, mark the paired samples with the same number. Otherwise leave the cell blank.
8.
Comment: when needed, write special requests
Test Type
Test No.
Test Name
Group No.
Group
Name
Sample Name
Pairing
Comment