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Sample Request Form
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First Name*
Last Name*
Title or Position*
Company Name
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E-mail Address*
Phone Number*
Fax Number
I would like a sample of:
Media for HUMAN Cells
ColonyGEL™ 1101 – Human Base Medium (no cytokines)
ColonyGEL™ 1102 – Human Complete Medium
ColonyGEL™ 1103 – Human Complete Medium without Epo
ColonyGEL™ 1104 – Human Enriched Complete Medium
Media for MOUSE Cells
ColonyGEL™ 1201 – Mouse Base Medium
ColonyGEL™ 1202 – Mouse Complete Medium
ColonyGEL™ 1203 – Mouse Complete Medium without Epo
ColonyGEL™ 1205 – Mouse Pre-B Cell Medium
Area of Research
I am familiar with Methylcellulose-based Media and have performed CFC assays in my lab
Yes, my current methylcellulose-based media supplier is
No, please contact me with additional information
I use Methylcellulose-based Media to study/determine
How many 100 mL bottles of media do you use or anticipate using per month?
Never used methylcellulose-based media before
< 1 bottle per month
1-2 bottles per month
3-5 bottles per month
> 5 bottles per month
Don't Know/Not Sure
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