INNOVEX
CUSTOMER ORDER FORM |
| Full
name:______________________________________________Date:________________ |
| Company
name:_____________________________________________P.O.#_____________
|
Credit
Card Number
____________________________________________________________
Exp. Date _____________________ CCV (three digit
security code) ___________________
Lab
User Name (if known):_____________________________________
E-mail (required):________________________Phone:_________________Fax:_______________ |
SHIP
TO ADDRESS |
| Company
name:___________________________Building/Room
number:_________________ |
| Attention
to:___________________Department:___________________________________ |
| Street
Address:_______________________________________________________________ |
| City:_______________________________________State:________Zip:_______________
International
Customers: Please provide us with a DHL, FedEx or UPS
account number. If you do not have an account, freight
charges will be added to your order.
My ------------------- account number is
---------------------------------
|
BILL
TO ADDRESS |
| Company
name:____________________________Building/room
number:_________________ |
| Attention
to:____________________________________Department:_____________________ |
| Street
Address:_________________________________________________________________ |
| City:_____________________________________________State:________Zip:_____________ |