Order Form

*Required fields

Contact 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 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.

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:

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 Information

Sample

Cell Name:

Species:

Passage Number:

Sex:

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.