Customer Information
(Fields in red are required)
User Name:
User Phone:
User Email:

 
Payment Information
Purchase Order Number:
Card Type:
Credit Card Number:
Expiration::
 
Ship To Information
(Fields in red are required)		Bill To Information
(Duplicated Billing Information
may be changed)
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: