The Biopolymer Laboratory
Department of Microbiology/Immunology
Phone 410-706-8553  Fax 410-706-0287
E-mail:  biopolym@umaryland.edu

CUSTOM DNA ORDER FORM

Principal Investigator:                                                                   Date:                         
Department and School:                                                                                                   
E-Mail Address:                                                                                                                 
Name of Requestor: (if other than P.I.)                                                                          
Phone:                             Account to be charged:                                                            
Signature of P.I. or authorized person:                                                                          
User sample name:                                        Bio-Lab sample name:                            
(Please note:  orders can still be faxed or e-mailed to the Biopolymer Lab;  however, this signed form must be presented when picking up order.)

For Core Use Only