Fax Order Form

Please print out this form, fill it out, sign it, and fax or mail it back to:

Exalpha Biologicals, Inc.
5 Clock Tower Place, Suite 255
Maynard, MA 01754 USA

Phone: 978-461-0435 Fax: 978-461-0436 Email: info@exalpha.com Attn: Customer Service Dept.

Purchase Order # :_______________

Credit card #:________________________ Exp. Date: ___________ CVV#: ________

Name on Card: ______________________________

Ship To:

Name ___________________________________________________________

Institute/ Company _____________________________________________

Address ________________________________________________________

Address ________________________________________________________

City ______________________________ State ________ Zip _________

Country _______________________

Phone ______________________ Fax _______________________ Billing Address (if different the above): Name ___________________________________________________________

Institute/ Company _____________________________________________

Address ________________________________________________________

Address ________________________________________________________

City ______________________________ State ________ Zip _________

Country _______________________

Phone ______________________ Fax _______________________ Products Wanted:

Cat#

Description

Size

Amount

Price*

Signature ______________________________ Date ____________________

* Pricing subject to change without notice, please call for latest price information.