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  C3 Disposables Reorder Form

Please provide the following information:
Date:
Company:
Contact Name:
Phone:
Email:
PO # (must receive hard copy)
Credit Card #:
Credit Card Expiration Date:
Name on Credit Card:

Item / Part #

Unit Cost (USD)

Quantity

Test Cells (100 cells/box) #CTC001SK

$750.00 per box 

 

Test Cells (500 cells/5 boxes or more) #CTC001SK-5

$600.00 per box

  

Extraction Solution (per bag) #04C035B1

$30.00 each

  

Vials w/caps (100 min.)

$100.00 box

  
     
Company:
Attn:
Street Address 1:
Street Address 2:
City, State, Zip

 
Preferred Shipper:
Shipping Account #:

Special Instructions:

Orders should ship within two weeks upon receipt of hard copy PO or Credit Card information and shipping account information.
 

For more information about Foresite, visit us or contact us at:
Foresite, Inc.
1982 S. Elizabeth St.
Kokomo, IN 46902
(765) 457-8095
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