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)
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