Product Request Form

Please complete this form to request the purchase of Apellis product. Email completed forms to medicalresearch@apellis.com. Alternatively, you may submit a request via the online form.

Apellis will review your request on a case-by-case basis. Apellis will consider only requests for product to be shipped in the US. Submission of this form does not guarantee Apellis’ approval of your request. Requests received on a non-Apellis form or with missing information will not be considered. Apellis may request additional information prior to approving or declining your request. Approved product shipments are non-returnable.

Note: this form does not apply to Apellis Investigator Initiated Trials, Collaborative Research, or Expanded Access. For more information about these programs, please visit the Medical Research and Resources sections on the left navigation bar.

Commercial Product Request Form

"*" indicates required fields

MM slash DD slash YYYY

SECTION A: GENERAL INFORMATION

SECTION B: SHIPMENT INFORMATION

ADDRESS*
BILLING INFORMATION (If different than shipping)
Will any product be shipped outside of the United States?*
Do you require specific shipping and handling (e.g., temp monitor)?*
Is the shipment receiving location for drug product a GxP facility capable of receiving and storing cold chain products?*
Do you require a COA/COC?*
Will this product be used in a Clinical Trial? If “YES” complete Required Sections C and D on page 3 of this form. If “NO” complete required Section D on page 3 of this form.*

SECTION C: REQUIRED FOR CLINICAL TRIALS

(REMS Certification will be required for Empaveli Only)
TRIAL REGISTERED ON CLINICALTRIALS.GOV?

SECTION D: ATTESTATION

By checking the boxes below, I confirm the following:*
This field is for validation purposes and should be left unchanged.