Hazmat Shipping Request Form You must have JavaScript enabled to use this form. Shipper's Information Department Name Requestor's Name Preferred Shipping Date Building Address Building Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Telephone Number E-mail Address FedEx Account Information 9-digit FedEx Account Number for Billing Recipient's Information Recipient's Name E-mail Address Company Name Shipping Address Shipping Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Telephone Number Is this an international shipment? Yes No Has the shipment been approved by the Export Control Office? Yes No If yes, Please Provide Approval Number Does This Shipment Involve Materials That Would Require A Materials Transfer Agreement (MTA)? Yes No If yes, Please Provide MTA 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 No If yes, specify: Are the samples preserved? Yes No If yes, in what? At what % solution? Is dry ice being used? Yes No 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 - None -mLuLLiterugmggramsKglbOther Container Material - None -GlassMetalPlastic Container Type - None -CylinderTubeBottleBoxDrum Additional Notes Shipment requests will be evaluated within two working days of form submission, and a timeline for shipping will be provided according to the complexity of the shipment. Please allow at least one week of advance notice for international shipments. EHS will complete the shipping papers, provide proper labels, and arrange for pickup of the package. EHS can provide UN-approved packaging, when required. If shipping samples with dry ice, the samples and dry ice should be in the box, but do not seal the box before inspection by EHS. Remove any old labels that are not associated with this shipment.
