Custom Manufacturing Request Form

Gibson Bioscience offers Custom Solutions to laboratories in need of preserving environmental isolates. Because every laboratory has a unique need and volume requirement, please complete the information below. We kindly request that you complete one form per isolate. This will help us evaluate your request and determine our ability to meet your needs.

In order to process your private strain, we require an Affidavit of Ownership/Authority and Hold Harmless Agreement, which will be provided to you as a separate document. The purpose of this document is to provide official documentation that you have given Gibson Bioscience permission to perform contract manufacturing using your company's biological materials, and that your company is the rightful owner of the biological materials. The signed and notarized Affidavit must be provided to Gibson Bioscience prior to or with the shipment of biological materials. We are also able to provide a Confidentiality Agreement upon request.

First Name*:
Last Name*:
Company*:
Job Title*:
Address Line 1*:
Address Line 2:
City*:
State / Province*:
Zip / Postal Code*:
Country*:
Phone*:
Email*:
Enter the microorganism name as you want it to appear for labeling purposes*:
Enter the strain identification number for labeling purposes*:
To what biosafety risk group is this microorganism classified?*:
Select your packaging preference*:
If other packaging is preferred, please describe:
Describe any specific labeling requirements for this product:
Is the specific application for this microorganism preparation for quality control?*:
If no, please specify the intended use:
How many times per month will a new microorganism preparation be used?*:
How often do you plan on re-ordering this strain?*:
What is the anticipated timeline of your project?*:

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