School of Pharmacy UNIVERSITY OF WISCONSIN - MADISON Mass Spec Sample Submission Form Samples submitted to our facility should be accompanied by either a printable Sample Submission Form or the Online Submission Form. Printable/Fillable Submission Forms: Protein/Polypeptide Sample Submission Form (doc) | Small Molecule Sample Submission Form (doc) Online Mass Spec Sample Submission Form Client InformationName* First Last Email* Phone*PI or Advisor*Affiliation (Department/Company)*Account/Fund to be charged*General Sample InformationSample name*Molecular formula*Please use "^" to denote superscript numerals and "~" to denote subscript numerals. Example: Barium bromate - dihydrate would be Ba(BrO~3)~2·2H~2O.Nominal mass*For Dry SamplesSample quantityUnitsmg/mlµ/mlSolubilityH20MeOHACNOther....For Wet SamplesSample concentrationUnitsmg/mlµ/mlSolventPossible impuritiesPercent puritySafety ConsiderationsPlease check all conditions that apply to your sample. Note: No radioactive samples will be accepted for analysis.Safety considerations None Carcinogenic Explosive Flamable Irritant Toxic Unknown Other... Special Handling RequirementsSpecial handling requirements None Air sensitive Light sensitive Store in refrigerator Store in freezer Other... Analytical InformationType of analysis MW determination Quantitation Framentation Other... Ionization techniqueAPCIESIMALDISpectrum type MS MS/MS LC/MS Ionization mode(+) ion(-) ion+/- ionMass range to scanWould you like your results emailed to your?YesNo