Product Orderform
To order our products, please fill out the following order form or contact us at one of the following numbers:
• Telephone 1-858-642-0978, ext. 231 or (Toll Free in USA) 1-888-723-4363
• Fill out our online order form and submit your order by fax to 1-858-642-0937.
*Mandatory Fields
Products on Order
Products Quantity Price
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Please include a 2013 IMGENEX Catalog with my order
Shipping Information
First Name Last Name
Institution E-mail
Department Mail Code
Street Address City
State Zip / Postal Code
Country Institution Type
Phone Fax
Position End User
Lab Manager
Purchasing Agent
Post Doc
Principal Investigator		 Special request
Billing Information
Institution Mail Code
Department City
Street Address 1 Zip / Postal Code
State Quotation/Promo No
Country
Payment Type Credit Card
Purchase Order		 Credit Card Type Visa Mastercard
American Express
Purchase Order Expiration Date
Credit Card Number Expiration Date
*CVV Number