INTENT TO SHIP HAZARDOUS MATERIAL FORM
1. Material Name or Constituents: 2. Form of Material
    (i.e. liquid, solid, etc):
3. Quantity of Material: 4. CAS number(leave blank if no cas number, or if the material is not under the Toxic Substance Control Act, type 'not needed'):
5. Manufacturer (if any): 6. Product Number (if any):
7. Shipping Destination: 8. Special Shipping Requirements
    (i.e. cold packs, dry ice, none):
9. Preferred shipping method: 10. Shipping account (if any):
11. Shipping priority: 12. Do you plan to transport this
      material off-campus, personally?
First Name: Last Name:
Date: Phone #:
Email: Campus Address/Pick-up Location:
Department: PI:
Notes: (maximum length = 255 characters)