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[pic] Form: CPAPB-SIF

| PRELIMINARY | |

|CUSTOM PEPTIDE SERVICE IDENTIFICATION FORM |Kinexus Order Number |

|ARRAY PRODUCTION Subject to terms of the Kinexus Proteomics Services Agreement |For Kinexus internal use only. |

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| |      |

Name:       Company/Institute:      

(Authorized Representative or Principal Investigator)

Particulars of Service Requested:

Please refer to the CSPP Services Customer Information Package for further details about these services. Complete the sections and check the boxes as appropriate. Areas indicated in light blue are for Kinexus use only and should not be filled. An electronic fillable copy of this form is available from the Kinexus website and by e-mail. If you need assistance completing this form, contact Dr. Dirk Winkler by calling toll free in North America 1-866-KINEXUS (866-546-3987) or by email at peptides@kinexus.ca.

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|A. CUSTOM SERVICE REQUESTED: |KINEXUS ID NUMBER |B. CPAPB-SIF IDENTIFICATION NAME: |

| |(Bar Code Identification Number) | |

|CelluSpots™ Kinase Substrate Array (CPAPB) | |Client ID:       |

| |For Kinexus internal use only. | |

|Synthesis of Cellupots™ arrays on glass slides of a set of |      |Use this ID name of your choice for your internal reference |

|given kinase substrate peptides from annotated | |and completion of the CPAP-SOF form. |

|phosphorylation sites. | | |

| | | |Product |Cost |

|C. PRODUCT DESCRIPTION: | | |Code |U.S. $ |

| | | |Kinexus use only. |Kinexus use |

| | | | |only. |

|Array |Unique Spots per |# Slides | | |

| |Slide | | | |

|Protein-tyrosine Kinase Substrates (1 array) |384 in duplicate |Pack of       |      |      |

|Protein-serine/threonine Kinase Substrates I + II (2 arrays) |384 in duplicate |Pack of      pairs |      |      |

|Test Packs | |  | | |

|Protein-tyrosine Kinase I Plus (one slide) |384 in duplicate | 2 duplicate |      |      |

|Protein-serine/threonine Kinase Substrates I + II (two slides) |384 in duplicate | 1 pair |      |      |

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|D. REMARKS: |

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Name of person completing this form Email Address/Facsimile Number/ Phone Number Date (y/m/d)

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