7965 Silverton Ave.

Suite 1309 San Diego, CA 92126

Tel: 858-547-8349 Fax: 858-547-8314 www.bioclon.com info@bioclon.com

Purchase/Credit Card Order Form

(Please Fill in the form and Fax it to 858-547-8314, If you have question, please call 800-860-5112)

Purchase Order Information: me:Co Contact Name: Institution Name: Billing Address 1: Billing Address 2: City: State:

Tel:

Fax: Purchase order#:

Email:

Zip:

Country:

Credit Card Information: Card Type (Please mark with X): 1. Visa _______2, Master: ________ 3. American Express:______ Card Number: Expiration Date: /M /Y

me:A Name on Card: Address 1: Address 2: City: Signature:

State: Date:

Zip: Tel:

Country:

Shipping Information: me:A Attention Name: Institute Name Shipping Address 1: Shipping Address 2: City:

Tel:

Fax:

Email:

State:

Zip:

Country:

Ship via (Please Mark With X): 1. Two days____2. Overnight_____3. International Express______ Product Ordering Cat # Unit Product Description Price (US $)