Customer Supply Orders.

Supply Request Form
Item	Individual Pricing	Quantity Required

2 oz Sterile Flip-Top Container (60 mLs)	$1.40

4 oz LPS Sterile Flip-Top Container (120 mLs)	$1.40

5 oz Sterile Custody Container (150 mLs)	$1.40

10 oz Sterile Custody Container (300 mLs)	$1.40

Drinking Water Sample Bottles (IDEXX)	$1.10

Letheen HydraSponge w/Gloves	$2.20

Letheen SpongeSicle w/Gloves	$2.20

RediSwab w/Letheen (10 mLs)	$2.15

*Sab Dextrose Agar (Deep Fill) Plate	$19.50

*TSA w/5% Sheep Blood Plate	$19.50

Round Bottom Sterile Sample Bag (52 oz. 7 in. x 13 in.)	$1.10

Whirl Pak Sterile Sample Bag (24 oz. 5 in. x 9 in.) (1 each)	$1.10

Whirl Pak Sterile Sample Bags (24 oz. 5 in. x 9 in.) (500/case)	$82.50

Sampling Supplies Shipping Kit (12 in. x 10 in. x 11 in.)	$27.50

*Available in increments of 10

Complete this form and save a copy for your records. Send a copy of this form by email to supplyrequest@cherneymicro.com. We will fill your request and notify you when the supplies have been sent.

**All Fields Below Are Mandatory**

COMPANY NAME:

COMPANY
CITY/STATE:

SITE
LOCATION:

SIGNATURE:

DATE:

EMAIL ADDRESS:

TELEPHONE:

NOTE: If you would like this to become a standing order, please email your request to supplyrequest@cherneymicro.com.
Standing orders for supplies are shipped the last Monday of every month.

For Office Use Only:
Packers Initials:	Freight Amount/Invoice#:	Date Shipped:	Shipping Method:

Verification Code: Enter the two words below seperated by a space.

Customer Supply Orders.

Supply Request Form