ORDER FORM FOR WOCKHARDT UK LTD PORCINE INSULIN

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