PREMIER Biosoft

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Order Using Purchase Order or a Credit Card

Purchase Order Credit Card

Your Information (Buyer)

First Name*

Last Name*

Institutional affiliation*

Department*

Address1

Country*

Phone1*

	-		-		-
Country	-	City/Area*	-	Phone*	-	Ext. (optional)

Phone2

	-		-		-
Country	-	City/Area	-	Phone	-	Ext. (optional)

Email*

Alternate Email

Information of the Principal Investigator (PI), if Available

A PI is the Principal Investigator of a lab/project. The license of this purchase will be registered to the PI(licensee). Check "Same as above" if you are the PI. If the PI is someone else, you can provide his/her information here, if available.

Note: The PI's information is required to register the purchased product but is not mandatory to process the order. The PI can also provide his/her information later while activating the product.

Same as above. PI is different.

First Name

Last Name

Institutional affiliation

Department

Address1

Country

Phone1

	-		-		-
Country	-	City/Area*	-	Phone*	-	Ext. (optional)

Phone2

	-		-		-
Country*	-	City/Area	-	Phone	-	Ext. (optional)

PI Alternate Email

Product Delivery Email

The product will be delivered electronically to your e-mail address above. if you would like us to send us the product delivery to an additional address, please specify it here:

Email (Optional)

Same as PI.

Asterisks (*) indicate required fields.

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