Cryogenic/BioScience Transportation Service Questionnaire

***ALL INFORMATION MUST BE COMPLETED BY THE CLIENT ***

PICK UP LOCATION INFORMATION / DELIVERY LOCATION INFORMATION
COMPANY/FACILITY
NAME / COMPANY/FACILITY
NAME
ADDRESS / ADDRESS
BLDG / ROOM # / BLDG / ROOM #
CITY / CITY
STATE / STATE
ZIP CODE / ZIP CODE
LOCATION
CONTACT / LOCATION
CONTACT
PHONE # / PHONE #
FACILITY
MANAGER / FACILITY
MANAGER
PHONE # / PHONE #

Completed paperwork is required for accurate pricing.

SECTION 1

Shipment Booking Contact: Phone: Email:

Proposed Shipment Date: Alternate Shipment Date:

SECTION 2

SECTION 3

LOADING REQUIREMENTS / PICK UP / DELIVERY
Is there a dock accessible to the freight? / /
If yes, will the dock accommodate a 53’ trailer / tractor combination?
(Must be capable of accommodating 85’ length and 13’6’’ height.) / /
Have all hallways, doorways and passages been verified large enough to accommodate the equipment being moved? / /

SECTION 4

SHIPMENT REQUIREMENTS
Is any material being shipped hazardous?
(If yes, indicate which hazards are to be shipped in Section 6 and list each hazardous item in Section 12.) /
What is the declared value of the shipment?
(TheCryoGuys provide $200,000 of cargo insurance on all loads. If declared value is greater than $200,000, supplemental cargo insurance will be obtained and fees passed on to the customer. Advance notice of at least 5 business days is required.) / $

SECTION 5

The following rental items are available for temporary use while in transit.
Please indicate number of units needed.
(The items listed are TCG property and available as rentals only. Additional fees apply.)
180L Cylinder of Liquid Nitrogen / -80 Electrical Freezer
-30 Electrical Freezer / +4 Electrical Refrigerator
Liquid Nitrogen Freezer
(30 racks) / LN2 Freezer Racks / 5*5*2 / 5*5*3

SECTION 6

Will any of the following be shipped? (If unsure of designation, contact TCG Safety Department at (888) 279-6489 ext 4.)

Biological
Agents / Infectious Substances / Non-Hazardous
Chemicals / Hazardous
Chemicals / Radioactive
Agents

** If yes, shipper is responsible for completing Section 12 of this questionnaire. Completed hazmat list is required for accurate pricing.

* If no, shipper is declaring all items in this category to be “non-regulated for transport” according to the Department of Transportation.

SECTION 7

TheCryoGuys offer a DOT compliant Hazmat Preparation Service at additional cost. The preparation service must be scheduled separately and in advance of shipment service.

Do you need a Hazmat Preparation Quote? (Includes chem manifest, UN packaging, labeling, MSDS) /

SECTION 8

Provide detailed description of any additional items(other than freezers listed in section 11)to be shipped in the same trailer: (See TheCryoGuys’ Service Agreement for additional freight allowances. Accurate dimensions, weight and number of pieces required - attach additional sheets as necessary.)

SECTION 9

Provide names and 24 hour phone numbers of primary persons responsible for research samples, etc., contained in cryogenic freezers:

Primary Contact Name

/

24 Hr Phone#

Secondary Contact Name

/

24 Hr Phone#

SECTION 10

Printed Name of Shipment Booking Party 24 Hr Phone

Signature of Shipment Booking Party Date

Cryogenic Freezer Specification Sheet

  • Please retrieve the following information from the manufacturer’s ID plate of all units to be shipped.
  • Contact TheCryoGuys for NEMA code help.

SECTION 11

Model # / Serial # / Amps/
Volts / NEMA
Plug Code
(Required) / Operating
Temp (C) / Dims /
(Outside L x W x H)
Weight Estimate
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

HazMat List

  • Please retrieve the following information from the hazardous material’s MSDS sheet.
  • If a “technical name” is required in addition to a “proper shipping name” (as is all Div 6.2 material), a separate line item must be entered for each and the technical name and/or strain of agent must be included.
  • This information is required in order to provide accurate pricing.
  • Use multiple sheets as necessary.

SECTION 12

Identification Number / Proper Shipping Name / Hazard Class / Packing Group / Volume (per primary container) / Quantity
(of primary containers)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

REV 08/2014 102.011