ORDER FORM FOR WOCKHARDT UK L TD PORCINE INSULIN

 

PRODUCT

QUANTITY (please indicate)

Cost

TOTAL

(please calculate)

Hypurin Porcine Neutral                      100iu 10ml vial

       

25.00

Hypurin Porcine Isophane                    100iu 10ml vial

 

25.00

 

Hypurin Porcine 30/70 Mix                    100iu 10ml vial

 

25.00

 

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

 

36.00

 

Hypurin Porcine Isophane 100u/ml 5x3ml cartridges

 

36.00

 

Hypurin Porcine 30/70 Mix 100iu/ml 5x3ml  cartridges            

                  

36.00

 

+ TNT Courier Cost (2 day service)

100.00

100.00

Administration Charge

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