UIC Confocal Imaging Center

Rudman Hall room 340, (603) 862-0632

Sample Submission Form

Please fill out as completely as possible. It is most helpful if you get this form to Mark Townley (Rudman 312) a day or two prior to your appointment.

Name Date

Phone Number

Faculty Approval: NameSignature

Email Grant/PO#

Address (if UNH Durham campus, what building and room #)

Sample Designation/ID#

Fluorescent Probe(s):

Name	Manufacturer	Maximum Excitation (nm)	Maximum Emission (nm)

Brief description of sample (e.g. sample source, fixed/living, sections/wholemount, mounting medium including its refractive index)

What information are you hoping to obtain from this sample?

Any toxic/hazardous compounds in sample? (specify)

Any literature citations you can provide that might help us help you? (e.g. containing similar M&M, showing relevant morphology or ultrastructure)

Optics optimized for use with #1.5 coverslips.