Intended Use Form – Advanced Biotechnologies

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INTENDED USE FORM

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To expedite processing of your order, please complete entire form.

Company Name *

Business Type (check all that apply) *

Biotech
Government
Hospital
Pharmaceutical
Reseller
Other
University

End User Name *

First

Last

End User Title/Department *

End User Phone Number *

End User Email Address *

Billing Address *

Shipping Address *

Purchaser Name *

First

Last

Purchaser Title *

Purchaser Phone Number *

Purchaser Email Address *

Catalog No. *

Product Description *

Quantity for Immediate Purchase *

Quantity Per Year *

Number of Years *

Intended Use *

Will your company make a profit from the use of this product or any of its progeny? *

If your intended use is research, what is the source of your funding?

Will the results of your research go through your Technology Transfer Office? *

Will your research be published? *

What is the expected time frame of your project? *

1 year
2 years
3 years
4 years
5+ years

Will the product be used for validation, verification, or to perform a service? *

Validation
Verification
Service
Other

Will the product or any of its progeny be used as a control for paid tests? *

US & Canada

410-875-7050

International

(+1) 410-875-7050

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