Order FormOrder Form *Required fieldsContact Information Lab Director: * Institution/Company/University: * Address 1: * Address 2: City: * State: * Zip code: * Country: * Phone * Contact name of person placing order: * Contact Email: * Email address to send results: * 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. Anticipated arrival/pickup date: Billing Information Billing address is the same as above Institute/Company/University: * Accounts payable contact: * Accounts payable email: * Address 1: * Address 2: City: * State: * Zip code: * Country: * Phone * Payment Information Anticipated payment method: PO/InvoiceCredit 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, payment instructions will be stated on the invoice, and a 4% processing fee will be added.Cell InformationSample Cell Name: Species: Passage Number: Sex: Approximate Doubling Time: On feeder layer? YesNo On basement membrane? YesNo Type of Analysis: StandardDuo iCS-KaryoComplexOther Special Instructions: Add another sample Remove sampleIf sending more than ten cell lines on a given day, please complete another Order Form. SubmitΔ