ORDER FORM
INTERNATIONAL DIRECTORY OF PLASMA
FRACTIONATORS - 2002
Price & Delivery
$595.00 (five hundred ninety five U.S. dollars). Shipment will be made by priority mail within the United States upon receipt of the order or payment, and by airmail for international orders. For overnight delivery, add $50.00 for international shipment, or $25.00 for domestic.
Payment
q BY ENCLOSED CHECK made in US dollars and issued on a US correspondent bank.
q BY WIRE TRANSFER to Fleet
Bank, Orange, Connecticut 06477
Account number 007103 7303, routing number 011 900 571. Swift address: FLTBUS3B.
q BY CREDIT CARD
q Visa q Mastercard / Eurocard q American Express
Card Number ________________________________________ Expiration date __________
Signature ___________________________________________________________________
Please print your name _________________________________________________________
q Please bill me q Payment follows
Report to be sent to:
Name ____________________________________________
Title _____________________________________________
Company _________________________________________
Address __________________________________________
Address __________________________________________
City/State ________________________________________
Zip/Country ______________________________________
Telephone _______________ Fax: ____________________
E-Mail _____________________Date: _________________