| 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) Pellets@Innovrsrch.com (Website) www.Innovrsrch.com |
| 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 |
| A Proforma Invoice will be provided for advance payment. See Bank Wire information on this form.  AMERICAN EXPRESS, MASTERCARD AND VISA ACCEPTED. NAME ON CARD: ________________________________ ACCOUNT NUMBER:_____________________________ EXPIRATION DATE:______________________________ |
Subtotal: Shipping and Handling: (Via Federal Express) Total: |
NOTE: Recipient is responsible for all duties and taxes on any orders shipped outside the United States.
SIGNATURE (Required): ______________________________________________________________________ |
| Ship To: Attn: |
Bill To: Attn: |
| 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 |