Order Form

BRAIN TUMOR ORDER FORM
Completed order forms can be submitted by email attachment to rcb@fhcrc.org or by fax to 206-667-5255
Name Customer #
Lab/Company
Address Shipping Address Billing Address (if different)
Street
City, State, Postal Code
Country
Phone Fax
email   Your PO# (if applicable)
Order Items
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):
Name Amount Name Amount Name Amount Name Amount
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:

RCB
Recipient

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