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 Name D-Gen Credit A/c reference number VAT Registration No. Contact Name Invoice Address Postcode / Zip Code Country Telephone No. Fax No. Email Address Nature of Business (please tick) Commercial Organisation Academic Institution Other Product Order Details: Purchase Order No. Delivery Address Product D-Gen Product Price per unit Quantity: Total Price Description Code Number number of units 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 firstname.lastname@example.org 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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