This form should be faxed to ECCAC prior to sending samples and the original must be included with the samples.  A Biohazard Risk Assessment must be completed in order for your samples to be accepted.  ECACC is required to asses the GMO status of all deposits prior to receipt.  Therefore, we will contact all depositors to advise them when we can receive samples.
Name
Job Title
Company
Address
Post Code
Country
Telephone
Fax
Email Address
Purchase Order Number
Mycoplasma Testing   Details of cell line to be submitted
Cell line name	Frozen    Growing
Details of medium for growth
Tests required	DNA Stain    Culture Isolation    PCR
Passaged twice off antibiotics	Yes    No
Any other comments or information
Mycoplasma Eradication   Details of cell line to be submitted
Cell line name	Frozen    Growing
Details of medium for growth
Any other comments or information
Sterility Testing   Details of cell line to be submitted
Cell line name	Frozen    Growing
Details of medium for growth
Tests Required
Any other comments or information