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 |
![]() NAME ON CARD: ________________________________ ACCOUNT NUMBER:_____________________________ EXPIRATION DATE:______________________________ |
Subtotal: Shipping and Handling: (Via Federal Express) Total: |
Ship To: Attn: |
Bill To: Attn: |