| CUSTOMER Information (Fields in dark red are required) | BILL TO Information (Information duplicated from above may be changed) |
| User Name: | | | |
| User Phone: | | | |
| User Email: | | | |
| Principal Investigator: |
Please use only principal investigator or lab supervisor name to obtain customer number. | NAME: | |
| DEPT, BLDG, RM#: | | DEPT, BLDG, RM#: | |
| INSTITUTION: | | INSTITUTION: | |
| STREET ADDRESS: | | STREET ADDRESS: | |
| CITY, STATE, ZIP: | , | CITY, STATE, ZIP: | , |
| COUNTRY: | | COUNTRY: | |
| PHONE: | | PHONE: | |
| FAX: | | FAX: | |
| E-MAIL ADDR: | | E-MAIL ADDR: | |
|
|
