ADDITIONAL KITS / MATERIAL ORDER FORM
FOR LATIN AMERICA

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*Pharmaceutical Company:

*Requestor's First Name:

*Requestor's Last Name:

*Protocol Number:

Covance Project Number:

*Principal Investigator Name:

*Site Number:

*Country:

*Phone Number:

*Email Address:

*Confirm Email Address:

*Standard Delivery
Allow 20 working days for delivery for Latin America. If you are located in an extended delivery area, your delivery may be longer.

*Expedited Delivery
Expedited orders are subject to additional charge and may require Sponsor's approval prior to shipment.

Lab Kit
Please write the full visit name as noted in your Investigator Manual. Kits ordered may require Sponsor's approval prior to shipment.

Additional Bulk Supplies
Please describe the additional material you may need. Bulk supplies ordered may require Sponsor's approval prior to shipment.

Comments

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