NHPP Reagent Order Form
FAX completed form to 310-328-4360 or EMAIL to "parlow@humc.edu" Direct any questions to A.F. Parlow at VOICE: 310-222-3537 or 310-415-2994
1. FedEx/UPS Acct# : ____________________(if known) Full Name: FedEx/UPS Internal Billing #: ________ Shipping Address: (Do NOT use P.O. Box. Use Building name, Credit Card Type: ___________________ street address, room number only) Credit Card #: ______________________ Credit Card Exp. Date: ______________ Purchase Order #: ___________________ Billing Address: ___________________ ___________________ City__________________ State_____ Zip_________ Country_______________ VOICE:(___)______________ FAX:(___)______________ E-MAIL:_______________
2. Reagent Request: a) Complete RIA Kits: b) Other Reagents [not listed in a)]:
Amount Species Reagent Description Hormone* AS**
* For Hormone, please specify if Biological (B), Reference (R), or
  Iodination (I).

**For Antisera, please specify if Radioimmunoassay (RIA), or
  Immunocytochemistry (IC).

______________________________ ______________________________ Signature Date ______________________________ Printed name