Title: Dr. Mr. Ms.

Name: ______________________________________________________________

Position: ____________________________________________________________

Company/Institution: __________________________________________________

Street Address: _______________________________________________________

City: ____________________________ State/Province: ______________________ 

Zip/Postal Code: __________________            Country: ______________________ 

Phone: ____________ Fax: ______________

E-mail: ______________________

Quantity: ________ @ $200.00 (USD) $______________

MD Institutions Tax Exempt #_____________________ or 6% sales tax ____________________

S&H US & Canada $4.50/order $___________________

S&H International $5.50/order $___________________

Total $__________________

Select Payment Type Cashier's Check Money Order   Payable in US Dollars.

P.O. Number: ____________________*     Phone Number: ________________________

* For P.O. include copy of the Institutional Purchase Order