"*" indicates required fields 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!Feb 12 2024: We are currently having technical difficulties with the web submission form. Please submit one form for each sample you are shipping, and hit submit once. We will receive the form but you will not currently receive an auto notification. Please send the tracking number to htslab@hwi.buffalo.edu and indicate you have filled in a form. We will notify you when we receive the sample and let you know if we have any questions. Thank you!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. Yes No If 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! HiddenSubmission 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! Yes No Contact Name* First Last Contact Email* Enter Email Confirm Email Is the contact the PI?* Yes No PI Name First Last PI Email Organization* Department Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Phone*NIH and or NSF Funding? Yes by NIH Yes by NSF If you are a NEW user please enter your password here.*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 HTX Center Policies and User Fees for full description and explanation of user fees.Payment methodPayment type*Purchase OrderSubscription IDCredit CardHWIPurchase Order* If purchase order is not yet available, please indicate that in the field.Do you need a quote for the Purchase Order? Yes Not needed Indicate if you require a quote for the PO. Billing information and address can be entered on the next page.Subscription ID* Please insert the subscription ID.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 SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Billing InformationInternal HWIBilling InformationSubscription 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 source Sample volume (μL)*Protein concentration (mg/ml)*Date purified* YYYY dash MM dash DD Date shipped* YYYY dash MM dash DD Buffer Components and Chemical Additives*Chemical NameConcentrationUnits Add RemoveTo add more components, click on the + symbol on the rightProtein Solution pH*Please enter a number from 0 to 14.Molecular weight (Da)*Subunit Information Add RemoveHas tryptophans?* Yes No Number 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)Max. file size: 2 MB.Amino acid sequence (optional)Additional Information/comments Additional 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 crystallization Unknown Yes No Detergents used for solubilizationChemical NameConcentrationUnits (enter % or mM) Add RemoveTo add more detergents, click on the + symbol on the rightDetergents used for purificationChemical NameConcentrationUnits (enter % or mM) Add RemoveTo add more detergents, click on the + symbol on the rightEnd of FormCheck the box below
