I4S Instrument Donation Form

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* 1. Name

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* 2. Email

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* 3. Phone

Instrument Information:

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* 4. Manufacturer

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* 5. Model

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* 6. Serial Number

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* 7. Month and year the instrument was manufactured

Date / Time

Date

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* 8. Computer hardware and Cytometer software included? If so, please provide the computer make and model.

Institutional Information:

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* 9. Name of Institution

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* 10. Address/ Location of the instrument

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* 11. Please provide the contact information for 1 or 2 individuals who work for this institution.

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* 12. When will the instrument be ready for donation?

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* 13. Is the instrument functional?

Yes

No

Unsure

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* 14. Are you able to transfer the service/ maintenance contract as a part of your donation?

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* 15. Do you still have shipping containers?

Yes

No

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* 16. Are you willing to fund transportation costs?

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* 17. Do you wish to remain anonymous?

Yes

No

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* 18. How did you hear about the Instruments for Science (I4S) program?

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* 19. Please provide photos of your donation.