| *Name of the shipper or person in charge of the shipment: |
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| *E-mail address of the shipper or person in charge of the shipment: |
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| *Telephone and Fax number of the shipper or person in charge of the shipment: |
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| *The "from" address as will appear on the shipment: |
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| *The destination nation of the shipment: |
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| *The "to" address as it will appear on the shipment and the name and telephone number of the consignee: |
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| *The ZIP code or postal number of the "to" address: |
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| *A description of the contents of the shipment. Please be as detailed as possible: |
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| If known, the area where the contents of the shipment were manufactured and the ingredients/compounds/etc. used in creating or manufacturing the contents of the shipment: |
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| *Weight of the contents of the shipment: |
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| Where applicable, desired manner of transport (e.g. can, bin, package, pouch, etc.): |
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| *The per-item size or sizes of the contents of the shipment: |
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| *Desired shipping temperature range: |
| Frozen (-70℃) |
| Frozen (-20℃) |
| Refrigerated (2℃ ~ 9℃) |
| Intended purpose of the contents of the shipment (e.g. research sample, gift, etc.): |
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| The declared value of the contents of the shipment as will be reported to customs: |
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| If this shipment will be one of a series of scheduled shipments, please list the interval of subsequent shipments. (e.g. monthly, weekly, etc.) Otherwise please print "one time only". |
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| If you have shipped the same contents via another shipping company in the past, please list the name of the previous shipping company: |
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| Affiliation of recipient (e.g. individual, corporation, university, etc.)： |
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| Has the recipient received such shipments previously? If so, please detail： |
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| Additional questions or comments： |
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