Product Order/Inquiry Form

How to Use This Form

Please type the required information in each field and then activate the “PRINT” button to obtain a pdf version. Customers should print and sign the completed form, and then return it to Kinexus Bioinformatics Corporation by facsimile transmission to 1-604-323-2548 or by e-mail to info@kinexus.ca. Should you have any questions, please contact our Technical Services representatives at 1-866-Kinexus (in North America) or 1-604-323-2547 Ext. 1. Once you have placed a product order with Kinexus, we will endeavor to ship the product within 2 business days or you will be contacted if there is a delay.

Customer Information
Salutation:	Dr. Mr. Ms.	* Completion Required
Customer Surname: *
Customer First Name: *
Title/Position: *
Institution or Company Name:
Department Name:
Unit/Room Number: *
Street Address: *
City: *
State/Province: *
Country: *
Zip/Postal Code: *
E-mail Address: *
Phone Number: *
Facsimile Number:
Alternative Contact Name:
Alternative Contact Email:
Alternative Contact Phone:
Repeat Customer?

Shipping Address
Same as above?

If not, please enter shipping info below
Unit/Room Number:
Street Address:
City:
State/Province:
Country:
Zip/Postal Code:

Payment Method
Purchase Order:
Accepted from institutions and companies with approved credit
Purchase Order Number:
Credit Card:
Card Type:	Visa MasterCard
Card Holder Name:
Card Number:
Expiry Date:

Billing Information
Invoicing: *	Customer Address Accounts Payable Address
Accounts Payable Contact
Salutation:	Dr. Mr. Ms.
Contact - Surname: *
Contact - First Name: *
Title/Position: *
Institution or Company Name:
Department Name:
Unit/Room Number: *
Street Address: *
City: *
State/Province: *
Country: *
Zip/Postal Code: *
E-mail Address: *
Phone Number: *
Facsimile Number: *

Short Survey
How did you learn about Kinexus products?
Direct Mail:
E-mail:
Internet Search:
Advertisement:
Referral:
Scientific Conference:
Other
If you are a previous Kinexus Customer please tell us how we did
Services:	Excellent Good Fair Dissatisfied
Products:	Excellent Good Fair Dissatisfied

Product and Pricing Information
Promotion and Bulk Discounts
Please Provide Quotation or Reference No.
Applicable Tax Rate (where required) *
Shipping and handling costs will be applied as most appropriate to the product.

Requested Products Enter either the "Product Name" or "Product ID" code to initially complete the fields in each row and adjust as desired No. Product Name Product ID Product Size Number of Units Unit Price Cost 1 2 3 4 5 6 7 8 9 10

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