Unidym - Products

Products

Product Order (Check all that apply)

Hipco™ “R” Raw SWNT	(g)
Hipco™ “P” Purified SWNT	(g)
Hipco™ “SP” Super Purified SWNT	(g)
Transparent Conductive Film (TCF), Research Grade	(A4 sheet)
Vertically Aligned Nanotube Array	(coupon)

1. Purchaser/Shipping Information: (Note: Please complete all information. We cannot ship to a PO Box)

Name (First, Last):

Company/University:

Address (Line 1):

Address (Line 2):

City/State/Zip/Country:

Telephone #:

Email:

2. Billing Information (If different from purchaser/shipping)

Name (First, Last):

Company/University:

Address (Line 1):

Address (Line 2):

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Telephone #:

Email:

3. Method of payment (Select one)

Credit Card (Please complete credit card information below)

Card Number:

Expiration Date (mm/yyyy):

CSC Code:

Zip Code:
(where bill is delivered)

Wire Transfer

Purchase Order #:

4. Additional Information:

a. Name of the person/organization that will be using this product:

b. Briefly describe the planned use/application of the product:

c. Will these products be used for a commercial purpose?

Yes No

d. Identify the country where this product will be used:

e. VAT number: (International orders only):

5. Additional Information:

I agree to abide by the Unidym Standard Terms and Conditions.

For credit card orders, complete and print this page,
then send by fax to (408) 636-7539.

Please call (408) 636-7500 if you require assistance