NanoLight TechnologyTM - Fax Order Form

Please fill out this form and print it then Fax your order to 928-367-1205.
Please include your:

Name:______________________________________________________________________

Email:______________________________________________________________________

Telephone:__________________________________________________________________

Shipping address:______________________________________________________________________

_______________________________________________________________________________________

Institution Name:_____________________________________________________________

Billing address:_______________________________________________________________

____________________________________________________________________________

Purchase order number:________________________________________________________

Grant or Reference number:____________________________________________________

Principal Investigator and/or contact person:_______________________________________

Method of Payment -We prefer and accept VISA or M/C:

# _______________________________________________ exp date: ______________________

Quantity(mg/mcgs) Cat# Description Unit Price (mg/mcg) Extension

__________ ___________ __________________ _____________ ________

*Shipping- Please add $30.00 shipping *Shipping: _____________
& handling on all U.S. orders.

International orders Total: _____________
add $60.00 (U.S.)

All orders are FOB and Net 30 days!