Nanoprobes On-Line Order Form

Welcome to our on-line order form. Please complete the following information:

Your information

Your name (required):
Organization (required):
Your telephone (required):	Fax:
E-mail (required):

Purchase Order Number (required):

Please note: this is not a secure server. Therefore, do not enter credit card numbers using this form. We are working to implement secure online ordering; in the meantime, if you wish to pay by credit card, please indicate this using the checkbox below and we will contact you by telephone to obtain your credit card information.

Ship to:

Attention:

Bill to:

Attention:

Order confirmation: Check if you would like us to send a copy of the output from this form to your e-mail address.

Order confirmation: Check if you require confirmation of prices and freight charges before order is shipped.

Credit card payment: check here if you wish to pay by credit card. We will contact you separately to obtain your credit card information.

Items

Please list the items you are ordering. If you order our Nanogold® kit (catalog number 2017) you must specify which antibody conjugate you want (2001, 2002, etc.) and which type of silver enhancement reagent (2012 or 2013): list the components in the "Item" box (don't worry about typing in more than the width of the box: it can hold up to 200 characters) or in the "Comments" box following the list. Under "Price," enter the total line price. Use the "Comments" box to describe any special orders. A quotation or prior approval must be obtained for all special or custom orders.

1: Cat #: Item: Size: Qty: Price: $

2: Cat #: Item: Size: Qty: Price: $

3: Cat #: Item: Size: Qty: Price: $

4: Cat #: Item: Size: Qty: Price: $

5: Cat #: Item: Size: Qty: Price: $

6: Cat #: Item: Size: Qty: Price: $

7: Cat #: Item: Size: Qty: Price: $

8: Cat #: Item: Size: Qty: Price: $

TOTAL PRICE: $

If you wish to order more than eight items, please use a second form.

NOTE: Freight and shipping charges will be pre-paid and added to the invoice. Domestic orders are shipped by Federal Express Standard Overnight Delivery: please allow $15.00 for items weighing less than 1 lb, and more for heavier items. International orders are shipped by Federal Express International Delivery: prices vary by location. If you wish to use another carrier or service, or have charges billed to your account ("bill recipient"), please specify in the "Comments" section. Do not send account information using this form: we will contact you to obtain details. For international orders, duties and taxes will be billed to the recipient.

Payments should be made in US dollars. Our terms are net 30 days. Nanoprobes, Incorporated reserves the right to change prices without notice: in the event that the prices you have entered are not correct, we will inform you before shipping.

Special instructions, requests or comments:

	Order confirmation: Check if you would like us to send a copy of the output from this form to your e-mail address.
	Order confirmation: Check if you require confirmation of prices and freight charges before order is shipped.
	Credit card payment: check here if you wish to pay by credit card. We will contact you separately to obtain your credit card information.

1: Cat #: Item: Size: Qty: Price:	$
2: Cat #: Item: Size: Qty: Price:	$
3: Cat #: Item: Size: Qty: Price:	$
4: Cat #: Item: Size: Qty: Price:	$
5: Cat #: Item: Size: Qty: Price:	$
6: Cat #: Item: Size: Qty: Price:	$
7: Cat #: Item: Size: Qty: Price:	$
8: Cat #: Item: Size: Qty: Price:	$
TOTAL PRICE:	$