Lock Box Request Form

Last Revised: July 08, 2021

To order a lockbox, please fill out and submit the following form. Lockboxes are clear acrylic. The price of the box will be charged to your account. If you have any questions please contact Jennifer Edmondson (215-898-2107). As a reminder, all stock material must be locked when in storage. The lockbox must be secured to the refrigerator/cabinet.

Licensee

Contact Person

Contact’s Phone #

Contact’s Email

Business Administrator

BA’s Phone #

BA's Email

Institution

UNIV

HUP

CHOP

WISTAR

Department

Account Number

Use

Radioactive Material

Select Agent

Lock Box

Small Lock Box ($180.00 - Inside dimensions : 5"W x 5"D x 5"H)

Large Lock Box ($200.00 - Inside dimensions : 12"W x 6"D x 5"H)

Restrainer and Lock ($16.00)

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