Purchasing Order Form - PDF by vas20779


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									                                                                ORDER FORM (U.S.)
NOTE: 1. Existing customers (with bioLytical Account No.) will receive an Order Confirmation with the agreed pricing.
      2. New or first time customers will be contacted by bioLytical Customer Service in order to set up an account and confirm eligibility.

Company Name:                                                                                                   Purchase Order No.:

Account No.:                                           CLIA No.:                                                Order Placed By:

Phone No.:                                             Fax No.:                                                 E-mail:

Catalogue and Product Description                                                                                                          Quantity

90-1019 - One INSTI™ HIV-1 Antibody Test with Support Materials                                                                                                Unit/s

90-1018 - 24 INSTI™ HIV-1 Antibody Tests with Support Materials                                                                                                Box/es

90-1020 - 24 INSTI™ HIV-1 Antibody Tests without Support Materials                                                                                             Box/es

80-1071 - INSTI™ HIV-1 Test Controls (Positive and Negative, 80 tests each)                                                                                    Box/es

Shipping Address:                                                                        Billing Address:

                                                                       Additional Requirements

Required Delivery Date: (Actual delivery date to be confirmed by bioLytical)

Special Shipping Instructions:

Documents to Accompany Shipment: (Check all that apply)
Certificate of Analysis                                                                 MSDS
Certificate of Origin                                                                   Other (Please specify)

Labelling and Packaging Requirements:
Standard Current Catalogue                                                              Other (Please specify)

Special Billing Instructions:

WARNING: The sale, distribution and use of the INSTI™ HIV-1 Antibody Test are restricted. By purchasing this device, you are doing so as an agent of a clinical
             laboratory and agree that you or any of your consignees will abide by the following restrictions on the sale, distribution, and use of the device:
1. Sale of the INSTI™ HIV-1 Antibody Test is restricted to clinical laboratories
     That have an adequate quality assurance program, including planned systematic activities to provide adequate confidence that requirements for quality will be met, and
     Where there is assurance that operators will receive and use the instructional materials.
2. The INSTI™ HIV-1 Antibody Test is approved for use only by an agent of a clinical laboratory.
3. Test subjects must receive the “Subject Information Brochure" and pre-test counselling prior to specimen collection, and appropriate counselling when test
   results are provided.
4. The INSTI™ HIV-1 Antibody Test is not approved for use to screen blood or tissue donors.

                                                                          bioLytical Use Only
Order Entered By:                                                                       Approved By:
                      __________________________________________                                           ______________________________________________
                                                                                                                               QA/QC Authorized Signer

QSP Form 72-01-05, Rev.A                                                                                                   Manufacturing Authorized Signer

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