HLA Tissue Typing – Sample Submission Form

Please electronically complete all pages of this form and email to along with your Purchase Order.

Do not send samples without prior authorization from ProImmune. Any samples received without having first been expressly authorized by ProImmune (as indicated by the provision of specific shipping labels to you) will at ProImmune's discretioneither be returned to you atyour cost and risk or be subject to an exception handling and receiptfee of $500/€500/£500.

/ Customer Contact Details
Institute name: / Institute
Department: / Department
Address 1: / Address
Address 2: / Address
Address 3: / Address
City: / City
Postcode/ZIP: / Postcode/ZIP
Country: / Country
Contact name: / Name
Telephone: / Telephone
Fax: / Fax
Email: / Email
ProImmune Quote #: Quote / Your PO Ref #: Reference

Health and Safety Declaration

Please complete all of the following details.
Note: failing to complete the below fields may lead to a delay processing your order.

Declaration:

I confirm that the samples I intend to send for tissue typing have been obtained from donors who have given informed consent to the intended use of these samples, and that the tissue typing data obtained will be used in life science research for analyzing and developing a better understanding of cellular immune responses. I accept that any samples received by ProImmune without having first been expressly authorized by ProImmune (as indicated by the provision of specific shipping labels) will at ProImmune's discretioneither be returned atmy cost and risk or be subject to an exception handling and receiptfee(minimum fee of $500/€500/£500).

Name: Name

Position: Position

Date: Today’s Date

Sample format to be sent

Please note that if your samples have not been tested for infectious agents, you may only submit genomic DNA for analysis.

If your samples have been tested for infectious agents by an approved method, and have been shown to be negative for HIV, you may submit these samples in any of the above formats; otherwise you must submit gDNA for analysis. If in doubt, please enquire.

Genomic DNA / ☐ / Whole Blood / ☐
Cryopreserved cells / ☐ / Saliva / ☐

Health & Safety Status (Only complete if sending whole blood, cryopreserved cells or saliva)

Have samples been tested for infectious agents?

Yes / ☐ / No / ☐

Please describe the disease state of your samples, if any:

Disease state

Check this box to confirm that testing methods are certified by an appropriate National Regulatory Body.

☐

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ProImmune Limited · The Magdalen Centre · The Oxford Science Park · Oxford OX4 4GA · United Kingdom

Registered in England No.: 387 3386 · VAT Registration No.: GB 749 9053 87

HLA Tissue Typing Service - Sample Submission Form

Please ensure that all vials have a unique identifier label that does NOT contain any confidential patient details (e.g. patient name) and is easily identifiable. Samples should not be labeled donor 1, donor 2 etc in order to avoid confusion with subsequent orders, and should be labelled on the vial rather than on the lid.

Loci to be Typed / Resolution / Sample Format
Tube Label / HLA-A / HLA-B / HLA-Cw / HLA-DRB1 / HLA-DRB3,4,5 / HLA-DQ / HLA-DP / Tier 1 / Tier 2 / gDNA / Saliva / Whole Blood / Frozen PBMC
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If you have more samples to be typed than can be recorded on this form, please contact or your sales representative for assistance.

Page 5 of 5

FRM_SM0311Z_V1.0

Tel: +44 (0) 870 042 7279 · Fax: + 44 (0) 870 712 0588 · Email: · Web: www.proimmune.com

ProImmune Limited · The Magdalen Centre · The Oxford Science Park · Oxford OX4 4GA · United Kingdom

Registered in England No.: 387 3386 · VAT Registration No.: GB 749 9053 87