|
 |
|
|
|
|
|
|
|
 Product Order Request Form For Purchase Order (P.O.#)
This form will be sent directly to our Sales Dept.
For credit card purchases please contact Sales Dept. at 877-PBL-8881.
*All Fields Required.
|
| First Name: |
|
|
|
|
|
| Last Name: |
|
|
|
| |
| Company : |
|
|
|
| P.O.#: |
|
|
|
| Phone: |
|
|
|
E-mail: |
|
|
|
|
| Fax#: |
|
|
|
| Ship to: |
|
|
|
|
|
| Address: |
|
|
|
|
|
| Building: |
|
|
|
|
|
| Room: |
|
|
|
|
|
| City: |
|
|
|
|
|
| State/Province: |
|
|
|
|
|
| Country: |
|
|
|
| Zip/PostalCode:; |
|
|
|
|
Check if Billing information is the same as Shipping. If Billing information is different enter below. |
|
|
|
| Billing Attn: |
|
|
|
| Address: |
|
|
|
| Building: |
|
|
|
| Room: |
|
|
|
| City: |
|
|
|
| State/Province: |
|
|
|
| Country: |
|
|
|
Zip/PostalCode: |
|
|
|
|
|
|
|
| Enter Product and Quantity Information. |
| How did you hear about PBL InterferonSource? |
|
|
| |
| *Shipping & handling costs include: ice fee ($25 Domestic / $40 International).
We ship via FedEx. You have the option to prepay or use an existing FedEx shipping account. |
| Please click here to review our Conditions of Sale. |
| |
| |
| This form requires that your browser support JavaScript and have it enabled. |
| |
|
|
|
|