Contact Name*

Address Line 1

Tel No

Fax No

Email Address*

BIOHAZARD RISK ASSESSMENT MUST BE SUBMITTED

The deposit is made in accordance with the terms of the Budapest Treaty 1977. I agree to abide by the conditions and regulations regarding the deposit of cell lines with HPA Culture Collections.

Name

Date

Invoice Address

Address Line 1

Address Line 2

Address Line 3

Address Line 4

Town

County

Post Code

Country

Cell Line for deposition*

Brief Description*

Identification/Name in full

Species and Strain

Organ/Tissue

HYBRIDOMAS

Immunogen

 Immunocyte donor

 Immortal partner

 Product Specificity

 Ig class/subclass

Screening Assay

ADDITIONAL INFORMATION

Full cell line name

Cell products/characteristics

Morphology

Passage No

Growth as suspension/attached line

CELL STORAGE CONDITIONS

Cell concentration

 Composition of medium

CULTURE CONDITIONS

Growth medium

%  Serum and type

Supplements (& conc)

Temperature

Gaseous phase

Split ratio (attached)

or (suspension) cells/ml

STERILITY CHECKS ALREADY PERFORMED

Bacteria

Mycoplasma

Fungi

Viruses

 OTHER RELEVANT INFORMATION