Credit Card Order Form (We accept Visa, MC and Amex) University AT Buffalo State University of New York Dr. Techung Lee Department of Biochemistry, University at Buffalo, 3435 Main Street, Buffalo, NY 14214, USA Tel/Fax: (716) 829-3106 Email: www.bmrservice.com Please Type or Print Clearly Order Date: Phone #: Purchaser: Email: Credit Card Type: please check Visa MC Amex Card Holder Name (as it appears on your credit card): Card Number: CCV code: Card Expiration Date (MM-YYYY): 3-digit number on the back of Visa & MC 4-digit number on the front of Amex Shipping Address: FedEx Account # (optional): Tax ID/VAT# (where applicable): Catalog # Description Quantity Unit Price Amount Express Shipping (inquire) Dry ice packing (inquire) Total Cost Please email completed form to chunglee@buffalo.edu. Thank you
Credit Card Order Form (We accept Visa, MC and Amex) University AT Buffalo State University of New York Dr. Techung Lee Department of Biochemistry, University at Buffalo, 3435 Main Street, Buffalo, NY 14214, USA Tel/Fax: (716) 829-3106 Email: www.bmrservice.com Please Type or Print Clearly Order Date: Phone #: Purchaser: Email: Credit Card Type: please check Visa MC Amex Card Holder Name (as it appears on your credit card): Card Number: CCV code: Card Expiration Date (MM-YYYY): 3-digit number on the back of Visa & MC 4-digit number on the front of Amex Shipping Address: FedEx Account # (optional): Tax ID/VAT# (where applicable): Catalog # Description Quantity Unit Price Amount Express Shipping (inquire) Dry ice packing (inquire) Total Cost Please email completed form to chunglee@buffalo.edu. Thank you
Credit_Card_Order_Form.docx