International Purchase Order Form Innovative Research of America
Please print or type all information.    2 North Tamiami Trail, Suite 404
   Sarasota, Florida 34236
  (Phone) 941-365-1406     (Fax) 941-365-1703
  (Email)  (Website)
Institution: _________________________________ Purchase Order Number: _____________________
Purchasing Agent: ___________________________ Investigator: _______________________________
Department: _______________________________ Department: _______________________________
Phone Number: ____________________________ Phone Number: ____________________________
Fax Number: ______________________________ Fax Number: ______________________________
E-Mail Address: ___________________________ E-Mail Address: ____________________________

Cat. No. No. of Lots Quantity/Lot Product Description Dosage Release Time Price/Lot Total Price

Mens Denver Broncos Antigua Navy Blue Quarter Zip Microfleece Pullover Jacket,Men's Oakland Raiders Nike Black 2015 Sideline Crew Fleece Performance Sweatshirt.Women's New York Jets Junk Food Green Boyfriend Fleece Pant,Houston Texans Big Logo Drawstring Backpack.Denver Broncos New Era White NFL White Front Neo 39THIRTY Flex Hat,Women's Kansas City Chiefs Majestic Red Game Tradition T-Shirt,Women's San Francisco 49ers Cuce Frontrunner Rain Boots New York Jets Jerseys for Sale.Mens New Orleans Saints Charcoal Field Of Play Pullover Hoodie,Youth New Orleans Saints Black 3-Pack T-Shirt Set.Newborn Baltimore Ravens Purple Sleep & Play Bodysuit,Men's San Francisco 49ers Nike Scarlet Vapor Performance Long Sleeve T-Shirt.Women's Tennessee Titans Nike Navy Blue Core Fan Marled Tank Top,Men's San Francisco 49ers Joe Montana Nike Gray Gridiron Gray Limited Jersey Cheap-New-York-Giants-Jets-Jerseys.Kansas City Chiefs Frosted Pint Glass,Mens Detroit Lions Pro Line Charcoal Lightweight Full Zip Hooded Jacket,Oakland Raiders 3-Time Super Bowl Champions Commemorative Tote Bag Bryce Petty Jersey Cheap.Mens Miami Dolphins Majestic Aqua Big and Tall Heart & Soul III T-Shirt,Women's Atlanta Falcons Devin Hester Nike Black Player Name & Number T-Shirt Ryan Fitzpatrick For Sale Cheap
A Proforma Invoice will be provided for advance payment.
See Bank Wire information on this form.     
NAME ON CARD: ________________________________
ACCOUNT NUMBER:_____________________________
EXPIRATION DATE:______________________________
Shipping and Handling:
(Via Federal Express)


NOTE: Recipient is responsible for all duties and taxes on any orders shipped outside the United States.

SIGNATURE (Required): ______________________________________________________________________
Ship To:

Bill To:

Bank Wire Payment Information
Payment via bank wire should be directed as follows:
    Accounts Payable /Financial Information
  In favor of:    *Contact Name:_________________________
BB&T Bank Innovative Research of America    *Phone Number:________________________
1800 Second St., Suite 100 2 N. Tamiami Trail Suite 404    *Fax Number:__________________________
Sarasota, Florida 34236 Sarasota, Florida 34236    *E-mail:_______________________________
Routing # (ABA) 263191387 Checking Account: #0000147816154    *Required
  SWIFT Code: BRBTUS33