High-Throughput Crystallization Screening Center Sample Submission Form | Hauptman-Woodward Medical Research Institute

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.
- 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!

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Submission Date*

Please check the website for the reservation deadline, package acceptance and plate setup dates.
Sample Type*
Are 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 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.

Billing Information
Billing 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 Country
Billing Information
Internal HWI
Billing Information
Subscription

Sample Information
Required Information for All Samples
This 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 Name Concentration Units

To add more components, click on the + symbol on the right
Protein Solution pH*
Please enter a number from 0 to 14.
Molecular weight (Da)*
Subunit Information
Has tryptophans?*
- Yes
- No
Number of tryptophans
Recommended storage temperature (℃) for sample upon arrival*
Recommended thawing temperature (℃ if frozen)*
Temperature (℃) requested for plate incubation*
Please submit image of the gel (optional)
Max. file size: 2 MB.
Amino acid sequence (optional)
Additional Information/comments
Additional information for membrane protein samples
Class of membrane protein
Predicted number of transmembrane domains
Lipids added to the sample to aid crystallization
- Unknown
- Yes
- No
Detergents used for solubilization
Chemical Name Concentration Units (enter % or mM)

To add more detergents, click on the + symbol on the right
Detergents used for purification
Chemical Name Concentration Units (enter % or mM)

To add more detergents, click on the + symbol on the right
End of Form
Check the box below

Fill out this form after you have reserved a spot in the current screening run.

Chemical Name	Concentration	Units

Chemical Name	Concentration	Units (enter % or mM)

Chemical Name	Concentration	Units (enter % or mM)