Step 1 of 5 20% Fill out this form after you have reserved a spot in the current screening run.To reserve a spot, make sure you have sent an email to htslab@hwi.buffalo.edu by the reservation deadline. Include contact name, PI name, institution, and number of samples. Thanks!Have you emailed us to reserve a spot for the upcoming screening run?*Please note the reservation deadline, package acceptance dates and plate setup dates are available on the website.YesNoIf you answered 'No' to the above question about reserving a spot for the upcoming screening run, please send an email to htslab@hwi.buffalo.edu BEFORE submitting this form. Thanks! Submission Date*Please check the website for the reservation deadline, package acceptance and plate setup dates.Sample Type*Soluble ProteinMembrane ProteinAre you a new user?*If you are a new user submitting multiple samples, please select 'Yes' for your first sample. After that, choose 'No' for the subsequent sample submissions. Thanks!YesNoContact Name* First Last Is the contact the PI?*YesNoPI Name First Last Contact Email* Enter Email Confirm Email Organization*DepartmentAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Primary Phone*NIH and or NSF Funding? Yes by NIH Yes by NSF For NEW users, to access images immediately through an ftp account, please supply a password.*Once an ftp account is established for you, the same username and password will be used to access the images for all future proteins you send. Once your samples are set up for crystal screening, you will receive information regarding how to access your ftp account. Please refer to HTCSC Policies and User Fees for full description and explanation of user fees.Payment methodPayment type*Purchase Order or Subscription NumberCredit CardHWIPurchase order or subscription number*If purchase order is not yet available, please indicate that in the field.We will contact you for your credit card information. Billing InformationBilling Contact Name* First Last Billing Email* Billing Phone*Billing Address* Same as contact Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Billing InformationInternal HWI Sample InformationRequired Information for All SamplesThis sample is a non-toxic, non-hazardous, non-infectious protein intended for crystallization and for laboratory use only*Please initial.Sample name (make unique for each sample)*Sample sourceSample volume (μL)*Protein concentration (mg/ml)*Date purified* Date shipped* Chemical Additives*Chemical NameConcentrationUnits To add more additives, click on the + symbol on the rightProtein Solution pH*Please enter a value between 0 and 14.Molecular weight (Da)*Subunit Information Has tryptophans?*YesNoNumber of tryptophansRecommended storage temperature (℃) for sample upon arrival*Select one-80º-20º4ºRecommended thawing temperature (℃ if frozen)*Select one4º30ºTemperature (℃) requested for plate incubation*Select one23º14º4ºPlease submit image of the gel (optional)Amino acid sequence (optional)Additional Information/commentsAdditional information for membrane protein samplesClass of membrane proteinAnchoredMonotopicTransmembrane (alpha helical)Transmembrane (beta barrel)Transmembrane unspecifiedUnknownPredicted number of transmembrane domainsLipids added to the sample to aid crystallizationUnknownYesNoDetergents used for solubilizationChemical NameConcentrationUnits (enter % or mM) To add more detergents, click on the + symbol on the rightDetergents used for purificationChemical NameConcentrationUnits (enter % or mM) To add more detergents, click on the + symbol on the rightEnd of Form
