Custom Solutions Request Form

Microbiologics offers Custom Solutions to laboratories in need of preserving environmental isolates.

All fields are required except where noted

International Distributors Only : Please enter the End Customer Contact Information below. Enter your
Distributor ID number for the Account ID #. In the Special Instructions, enter your Distributor Company
Name & Contact Information.

Contact Information:

First Name

Last Name

Job Title


Address Line1

Address Line 2



Postal/Zip Code


Telephone #


Microbiologics Account ID#
International Distributors must include their
Account ID#

Select a Service
Identification Service Only
Identification and Storage Service
Identification, Storage, and Ready to use Product

Is the specific application for this microorganism preparation for quality control?

Requested completion Date:

Indicate Biosafety Level

Microorganism name as you want it to appear for labeling purposes

Your Item number to be used for ordering.
If not indicated, Microbiologics will assign.

Passage # of culture being submitted.
If left blank, passage 0 will be assumed.

Preferred Medium
Include Brand & Catalog Number

Preferred Incubation Temperature

Preferred Incubation Time

Preferred Incubation Atmosphere

Alternate Medium *Check if applicable

How often do you plan on ordering this strain?

Special Instructions

Custom Solution Terms:

Customer’s specific strains have not been obtained, nor have they been delivered, produced or manufactured from biological materials originally obtained from the American Type Culture Collection (“ATCC”).


Customer’s specific strains originated from biological materials obtained from ATCC and customer has obtained a written commercial use license (“License Agreement”) from ATCC that authorizes it to engage a Third Party for contract manufacturing services.

Microbiologics does not perform validations or shelf life testing on Custom Solutions products; this allows us to provide you with product in a shorter timeframe.

I agree to the Custom Solutions terms indicated above.

I acknowledge Microbiologics will have use of this strain unless otherwise indicated.

I do not want Microbiologics to have use of this strain outside of the scope of my custom solutions order.