ORDER FORM FOR WOCKHARDT UK LTD BEEF INSULIN

 

PRODUCT

QUANTITY (please indicate)

Cost

TOTAL

(please calculate)

Hypurin Bovine Neutral                      100iu 10ml vial

        

25.00

Hypurin Bovine Isophane                    100iu 10ml vial

 

25.00

 

Hypurin  Bovine Lente                        100iu 10ml vial

 

25.00

 

Hypurin Bovine Protamine Zinc           100iu 10ml vial

 

25.00

 

Hypurin  Bovine Neutral 100u/ml 5x 3ml cartridges

 

36.00

 

Hypurin Bovine Isophane 100u/ml 5x3ml cartridges

 

36.00

 

+ TNT Courier Cost (2 day service)

1

100.00

100.00

Administration Charge

1

100.00

100.00

 VAT for European countries only 17.5%

 

 

TOTAL AMOUNT PAYABLE

 

            PAYMENT (Please tick choice)                                                                                                                                               a)                        By Credit Card

                                Please charge my:

 i.            Visa

                                                ii.             Mastercard             

iii.                  Access

iv.                   Eurocard

Card Number :

 

 

 

 

 

 

 

Expiry Date:  __/__

                Cardholders Name (as shown on the card):___________________________________

            Cardholders Address: ________________________________

                                     ________________________________

                                               ________________________________

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

Signed.                             Date..

b)            By Banker's Draft drawn on a U.K Bank (your local Bank should be able to arrange this)

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

                      (CP Pharmaceuticals is a wholly owned subsidiary of Wockhardt UK)

                                            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) to:

Export Department

Wockhardt UK  Ltd

Ash Road North

Wrexham Industrial Estate

Wrexham, LL13 9UF

United Kingdom

Telephone Number:                          + 44 1978 669201

Fax Number:                          + 44 1978 661262