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Customer Reference No.& Date :
Sample Particulars : (Please provide accurate and legible information)
Sl No.Sample Name *Application No.(ANDA/NDA Cft. if available)Code/Batch No.Mfd.Dt.Exp.Dt.Manufactured ByB.SizeQty.Sub.Test RequiredStandardSpec.PurposeAction


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)?
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