W.M. Keck Biotechnology Laboratory at Yale University
Large Scale Peptide Synthesis Order Form

Full Name (submitter) ________________________________   Telephone _________________

P.I. _______________________________________________   Telephone _________________

Institution: ____________________________________________________________________

Street Address: _________________________________________________________________

Department:______________________   Building: ____________________   Room: ________

City: _________________________________   State __________   Zip: ___________________

P.O.# orYale Charge # ________________________________________   Date _____________

USE THREE-LETTER ____  AND SINGLE LETTER CODES (  )
FROM AMINO-TERMINUS TO CARBOXY-TERMINUS

AMINO-TERMINUS:    [   ] FREE    [   ] ACETYLATED    (CHECK ONE)
COOH-TERMINUS:     [   ] FREE    [   ] AMIDATED      (CHECK ONE)

Primary use _____________________________________________________________________

Possible toxic or related effects (even remote) _________________________________________

______________________________________________________________________________

Unusual procedures or amino acids even if already indicated: _____________________________

______________________________________________________________________________

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FAX order to (203)737-5644     Please confirm receipt of order by phone at (203)737-2565