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Requisition to Purchase Radioactive Material Form

Complete this form to submit your requisition online, or complete and fax this PDF (print) requisition form to 3-4951. Please contact Curtis Kwasniewski if you have questions about radioisotope ordering procedures.

Contact Information

Request Date
PI Name
Account Number
Center Number	(You may enter up to 3 different center numbers.)

The following information is required to verify that you are authorized to purchase radioactive material for this Principal Investigator:
Name of Authorized User or Representative		Last four digits of SSN

Phone
Email	A summary of your requisition will be sent to this email address.
Delivery Location (Building & Room)

Radionuclide Information

Vendor
Catalog Number:
Number of Units
Radionuclide
Activity/Unit:	mCi
Total Activity:	mCi
Chemical Form
Delivery Date
Cost/Unit $

Special Instructions or Comments

To provide you with a written copy of this order for your records, a summary of your requisition will be sent to the email address you provided.

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