Purchase Order Form Innovative Research of America
United States    2 North Tamiami Trail, Suite 404
   Sarasota, Florida 34236
  (Phone) 941-365-1406     (Fax) 941-365-1703
  (Email) [email protected]  (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
          
          
          
          
          
          
AMERICAN EXPRESS, MASTERCARD AND VISA ACCEPTED.
NAME ON CARD: ________________________________
ACCOUNT NUMBER:_____________________________
EXPIRATION DATE:______________________________		 Subtotal:
Shipping and Handling:
(Via Federal Express)

Total:
Ship To:




Attn:		 Bill To:




Attn:

PLEASE COPY THIS FORM FOR FUTURE ORDERING