Purchase Request Form
Pharmaceutical for Research Use Only.
Email address *
Requestor Name (First, Last ) *
Your answer
Requestor contact number *
Your answer
Principal Investigator (Lab) *
Your answer
Department *
Recharge ID
Your answer
FAU- This Transaction will be processed as a Non-PEAR *
Your answer
CSUA# (for Controlled Substances Only)
Your answer
Use (Protocol# or describe use)
Your answer
Species ( if applicable)
Your answer
NDC# or catalog number (if available)-
Your answer
Product Name
Your answer
Concentration
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Type
Amount (size of individual container)
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Quantity
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Quantity type
Would you like to be notified with the cost of the product prior to ordering?
Would you like to be notified if the cost of the product is under $100.00 prior to ordering
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