USA ORDER FORM FOR CP PHARMACEUTICALS’ BEEF INSULIN 
(one of 4 FDA required documents)

PRODUCT	QUANTITY (please indicate)	COST	TOTAL (please calculate)
Hypurin® Bovine Neutral 100iu 10ml vial	______	£18.48	£_________
Hypurin® Bovine Isophane 100iu 10ml vial	______	£18.48	£_________
Hypurin® Bovine Lente 100iu 10ml vial	______	£18.48	£_________
Hypurin® Bovine Protamine Zinc 100iu 10ml vial	______	£18.48	£_________
+Courier Cost (2 day service)	1	£39.80	£39.80
TOTAL AMOUNT PAYABLE			£________

 

PAYMENT (Please tick choice)

[  ] A) By Credit Card

Please charge my:

1. [  ] Visa

2. [  ] Mastercard

3. [  ] Access

4. [  ] Eurocard

Card Number

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Expiry Date: ___ ___/___ ___

I authorise you to debit my credit Account with the above amount.

Signed ________________________________________________

Date ___ ___/___ ___/___ ___ ___ ___

[  ] B) By Banker's Draft

I enclose a Banker's Draft in Pounds Sterling payable to CP Pharmaceuticals Ltd

DELIVERY DETAILS

These details are extremely important, as the insulin will need to be refrigerated immediately upon receipt.

Delivery Address:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Contact Name:___________________________________

Telephone Number:__________________________

Fax Number:         __________________________

Please return this form (fax or post) with the three documents mentioned overleaf to:

Export Department
CP Pharmaceuticals Ltd
Ash Road North
Wrexham Industrial Estate
Wrexham, LL13 9UF
United Kingdom

Telephone Number: + 44 1978 669221
Fax Number: + 44 1978 669230

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