I4S Instrument Donation Form Question Title * 1. Name Question Title * 2. Email Question Title * 3. Phone Instrument Information: Question Title * 4. Manufacturer Question Title * 5. Model Question Title * 6. Serial Number Question Title * 7. Month and year the instrument was manufactured Date / Time Date Question Title * 8. Computer hardware and Cytometer software included? If so, please provide the computer make and model. Institutional Information: Question Title * 9. Name of Institution Question Title * 10. Address/ Location of the instrument Question Title * 11. Please provide the contact information for 1 or 2 individuals who work for this institution. Question Title * 12. When will the instrument be ready for donation? Question Title * 13. Is the instrument functional? Yes No Unsure Question Title * 14. Are you able to transfer the service/ maintenance contract as a part of your donation? Question Title * 15. Do you still have shipping containers? Yes No Question Title * 16. Are you willing to fund transportation costs? Question Title * 17. Do you wish to remain anonymous? Yes No Question Title * 18. How did you hear about the Instruments for Science (I4S) program? Question Title * 19. Please provide photos of your donation. Done
