Order Form

*Required fields

Contact 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 Information

Choose 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:

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 Information

Sample

Cell Name:

Species:

Passage/Population Doubling Number:

Approximate Doubling Time:

On feeder layer?

On basement membrane?

Type of Analysis:

Special Instructions:

Add another sample Remove sample

If sending more than ten cell lines on a given day, please complete another Order Form.