Purchase Order Form - DOC - DOC by dfhrf555fcg


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									   New technologies for detection and prevention of prion diseases

                                 D-Gen Ltd - Purchase Order Form

Customer Information: Please note existing customers with a D-Gen credit account reference number need only
fill in the company/institution name, D-Gen credit a/c ref. no. and product order details.

Purchasing Company or Institution
D-Gen Credit A/c reference number
VAT Registration No.

Contact Name

Invoice Address

Postcode / Zip Code
Telephone No.
Fax No.
Email Address

Nature of Business (please tick)
                                        Commercial Organisation
                                        Academic Institution

Product Order Details:

Purchase Order No.
Delivery Address

Product                D-Gen Product          Price per unit         Quantity:               Total Price
Description            Code Number                                   number of

            Total Order Value (UK customers please add 17.5% VAT)

Mode of Payment (Please Tick)
                                            Cheque           Bankers Draft      Bank Transfer      Account

I confirm that I have seen and agree with the D-Gen Terms and Conditions of Business.

Name : _____________________                                     Signature ______________________

Position:       _____________________                              Date:_____________________

Please post order with cheque/bankers draft made payable to “D-Gen Ltd” to D-Gen Sales, Dept of Neurology, St
Mary’s Hospital, London W2 1NY. Account and Bank Transfer Customers may email orders to sales@d-gen.co.uk or
fax to +44 207 8378047.
Note: No contract for the purchase of any goods will be formed until D-Gen has issued a written confirmation of
order acceptance.

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