New Customer Application

Part One: Contact Information

Information for Primary Investigator who will be using the Aplysia:

Name
Title
Mailing Address
City
State
Zip Code
Country
E-mail Address
Lab Phone ( ) -
Office Phone ( ) -

Information for person ordering animals: Lab assistant, Purchasing agent

Name
Title
Mailing Address
City
State
Zip Code
Country
E-mail Address
Office Phone ( ) -
Other Phone ( ) -
Fax

Part Two: Shipping and Billing Addresses

Ship the animals to this address:

Name or C/O
University or Facility
Address
Address 2
City
State
Zip Code
Country

Send bill to this address:

Name or C/O
University or Facility
Address
Address 2
City
State
Zip Code
Country

Part Three: Payment Information

Payment options

(Please call Colleen at 305/421-4941 with credit card information. We need name on card, card number, expiry date, 3 digit code on the back of card.)

have my own Federal Express Number.

My Federal Express Number is

Tax I.D Number:

For Profit

Part Four: Project Information

Aplysia may be ordered for research, teaching, exhibition and other purposes. Please help us track the uses of these animals (important for us and our funding agency, NIH).

Will these animals be used for (check all that apply):

Research
Teaching
Exhibition
Other

Will these animals be used on a research project funded by (check all that apply):

NIH
NSF
HHMI
Other

Please provide a short description of the research you will be conducting with the Aplysia: