||BRAIN TUMOR ORDER FORM|
|Completed order forms can be submitted by email attachment to email@example.com or by fax to 206-667-5255|
|Address||Shipping Address||Billing Address (if different)|
|City, State, Postal Code|
|Your PO# (if applicable)|
|For detailed information on each item, please see our web site at www.btrl.org.
Please enter desired type and quantities in the blue boxes. Totals will calculate automatically.
|Item#||Item||Unit price||Quantity||ITEM TOTAL|
|RCL40003 Brain tumor line||$ 50.00||0||$ –|
|Enter the type of brain tumor line requested (maximum of 10 vials per line):|
|RCL40004||Handling fee, Brain tumor line||$ 30.00||$ –|
|RCD40043||Shipping Fees||$ 1.00||$ –|
|Order Total*||$ –|
|Please note: *Shipping charges will be added to your invoice total. These charges are avoided by providing your own FedEx account number.
Prepayment is not required. Any adjustments will be reflected on your final invoice.
|Cell Bank use only||Received Date:||Shipped Date:||FedEx Account Used:||