Order FormOrder Form *Required fieldsContact Information Lab Director: * Institution/Company/University: * Department: * Address 1: * Address 2: City: * State: * Zip code: * Country: * Phone * Contact name of person placing order: * Contact Email: * Email address to send results to: * Transport InformationChoose one: * Drop off at 5501 Fortunes Ridge Drive, Suite O, Durham Ship overnight Specimen pick up by KaryoLogic courier in Durham, Wake, or Orange County, NC. You will be contacted shortly to make arrangements. Estimated arrival date: Billing Information Billing address is the same as above Institution/Company/University: * Accounts payable contact name: * Accounts payable email: * Address 1: * Address 2: City: * State: * Zip code: * Country: * Phone * Payment Information Anticipated payment method: PO/Invoice Credit Card Purchase Order Number: Invoice will be sent after work is completed and results are emailed. Payment is due 30 days from invoice date. If paying by credit card, after the work is completed and the results are emailed, the Accounts Payable person listed above will be contacted for credit card information details.Cell InformationSample Cell Name: Species: Passage/Population Doubling Number: Approximate Doubling Time: On feeder layer? Yes No On basement membrane? Yes No Type of Analysis: Simple Standard Complex Other Special Instructions: Add another sample Remove sampleIf sending more than ten cell lines on a given day, please complete another Order Form. Submit If you are human, leave this field blank.