1. Name
2. Affiliation
3. E-Mail Address
4. Phone Number
5. Mailing Address

   1. Address
   2. Addressoptional
   3. City
   4. State
   5. Postcode
   6. Country

1. Name
2. Biochemistry / Physiology
3. Actions
4. Chemical StructureImage or Chemical Structure File, 8MB Max
5. Material Safety Data Sheet8MB Max
6. Toxicity and Safety

   Please describe any known toxicity information and safety precautions

   1. Systemic Dosage Limitations
   2. Target Organs
   3. Safety Statements
   4. Risk Statements
   5. Hazard Codes
   6. Otheroptional
7. Solubility in Common Solvents
8. Known Instabilitiese.g., to light, etc.
9. Quantitative Measurement

   Please desribe available analytical procedures for quantitative measurement of chemical entities

   1. In Vitro
   2. In Vivo

1. Desired Target Organs
2. Desired Concentration in Target Area
3. Desired Time Frame of Chemical/Therapeutic Activity in Target Area

Please describe the level of scientific collaboration envisioned

• Product delivered for client research
• In vivo proof of therapeutic efficacy completed through collaboration at Saoirse
• Other (please explain)

1. Time Requirements

   1. Desired Product Delivery DateYYYY/MM/DD
   2. Desired Proof of Therapeutic Efficacy Delivery Date (If Saoirse Involved)YYYY/MM/DD
3. Quantity Required