Hazmat Shipping Request Form

Shipper's Information

Requestor's Name *

Shipper's Name

Department Name

Building Address

City, State, Zip Code

Telephone Number

E-mail Address

Recipient's Information

Recipient's Name

Company Name

Shipping Address

City, State, Zip Code

Telephone Number

E-mail Address

Is this an international shipment?

Yes

Has the shipment been approved by the Export Control Office?

Yes

FedEx Account Information

Sender's 9-digit FedEx Account Number

Recipient's 9-digit FedEx Account Number

Description of the Material Being Sent

If the material is from a human or animal source, reference any technical names, strains, etc. If the material is a chemical, reference any chemical names and percent of solution.

Do the contents contain any pathogens, viruses, or anything harmful to humans or animals?

Yes

If yes, specify:

Are the samples preserved?

Yes

If yes, in what?

At what % solution?

Is dry ice being used?

Yes

You must provide your own.

If yes, how many pounds?

Note - must use the accurate weight of dry ice that will be used at the time of the shipment

Contents of Package

Number of Primary Containers in Package

Volume Per Primary Container

Units

Container Material

Container Type

Additional Notes

The samples and dry ice should be in the box, but do not seal the box. Remove any old labels that are not associated with this shipment. Please give 24hr advance notice to allow for scheduling. We will make every effort to accommodate same-day requests, but you must understand there may be prior requests being processed and there will be no guarantee your shipment can go out on short notice. EHS will complete the shipping papers, provide proper labels, and arrange for pickup of the package. EHS can provide UN-approved packaging, when required.

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