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LOCK BOX REQUEST FORM

To order a lock box, please fill out and submit the following form. Lock boxes are clear acrylic. They may be picked up at our lab in 421 ANAT/CHEM between 10:00 a.m. – 12:00 p.m. Monday through Thursday and 1:30 p.m – 3:00 p.m. Fridays. The price of the box will be charged to your account. If you have any questions please contact Eileen Normoyle at 215-898-2134. As a reminder, all stock material must be locked when in storage. The lock box must be secured to the refrigerator/cabinet.

* Licensee:
* Contact Person:
* Contact’s Phone #:
* Contact’s Email:
* Business Administrator:
* BA’s Phone #:
* Mailing Address:
* Institution:
UNIV HUP CHOP WISTAR
* Department:
Account Number: - - - - - -
* Use:
Radioactive Material Select Agent
* Lock Box:
Small Lock Box ($180.00 - Inside dimensions : 5"W x 5"D x 5"H)
Large Lock Box ($200.00 - Inside dimensions : 12"W x 6"D x 5"H)
Restrainer and Lock ($16.00)
(small and large lock boxes come with a restrainer (the price of the restrainer is included)).

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