Credit Card Payment Form - via Email

Please complete all required fields, attach and email to us at info@narishige-usa.com. For the credit card information, you can call us at 800-445-7914 or you can request us to call you. Shipping address must include street address. UPS does not deliver to post-office boxes.

Complete the form below, print, sign, and fax to 631-841-0066.

* Required Fields

BILLING INFORMATION:

*	Name:
	Department:
*	University or Company:
*	Street:
	Street2:
*	City:
*	State/Province:
*	Postal Code:
	E-mail:
*	Phone:
	Fax:
	Tax Exempt Number:

SHIPPING ADDRESS: (If different from above address.)

Same as billing address

*	Name:
	Department:
*	University or Company:
*	Street:
	Street2:
*	City:
*	State/Province:
*	Postal Code:
*	Phone:

*	Residential or Business Address: Residential / Business

Purchase/Repair:

*	for:	PURCHASE / REPAIR
	Quotation Number:

Model No.	Unit Price	Qty.	Extension
	US$		US$
	US$		US$
	US$		US$
	US$		US$
	US$		US$

* Shipping / Handling Fees will be added to the total amount and be charged if applicable.

Additional Request:

* The following page requires that you view and print PDF files.
You must have Acrobat Reader installed on your computer. You can download Acrobat Reader free from the Adobe web site below.

https://www.adobe.com/products/acrobat/readstep2.html

Cardholder Signature:______________________________