EQAS 2015 Order Form

2015 ORDER FORM
New Customer
Participant
Information
Existing Customer
A pre-populated, automatic renewal will be sent to the primary contact person. Please contact the NRL if you have
not received this form.
Organisation Name
Department:
Street Address:
City/Suburb:
State:
Country:
Post Code:
Contact Name:
Contact Title:
Dr.
Ms.
Mr.
Mrs.
Miss
Phone:
Contact Position:
Fax:
Email:
Same as Participant Information
Billing Information
Organisation Name
Department:
Street Address:
City/Suburb:
State:
Country:
Post Code:
Contact Name:
Contact Title:
Dr.
Ms.
Mr.
Mrs.
Miss
Phone:
Contact Position:
Fax:
Email:
Shipping Options
International Participants Only
Door-to-Door - NRL will ship to your facility and add shipping and customs clearance costs to
your invoice.
Door-to-Airport (not applicable for NAT programs) - We will ship to the airport of entry and
add shipping costs only to your invoice; you will arrange and pay for customs clearance.
Authorisation
Do you require an import permit for EQAS samples?
Yes
No
I Yes, do you have an import permit for shipping time period?
Yes
No
By placing your order you agree to the Standard Terms.
Authorisation Name
Signature
Payment Options
Payments options will be specified on the invoice.
Purchase Order Number (if applicable).
Standard Terms
1. By placing your order you agree to these Standard Terms. An invoice will be issued upon receipt of your order.
2. All prices are in the currency as indicated. Prices are subject to change - current price list is available online (www.digitalpt..com).
3. Prices exclude shipping and handling fees. These will be added to your invoice.
4. Prices for Australian participants exclude GST.
5. Prices for international participants exclude applicable customs clearance charges and taxes and holding fees, which shall be your sole responsibility.
6. Payment in full is required before first shipment date.
7. Due to the nature of these programs and test materials, all sales are final.
8. Shipments and/or performance information may be withheld for overdue accounts.
9. Test samples may contain pathogenic materials: you assume all risk and responsibility for their receipt, handling, storage use and disposal.
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2015 ORDER FORM
Organisation Name
Department
DigitalPT ID
PROGRAMS ORDERED
Order
Code
(B)
Test
(A) No. of
Events X Programs Extra
Panels*
Samples
Program Name
(C): Price Per Program
AUD ($)
EURO (€)
MMBS4320fMultimarker Blood Screening Serology
3x20
1,875.00
1,500.00
NATA4315 Multimarker Blood Screening NAT
3x15
2,400.00
1,440.00
HEPM435
Hepatitis Serology - Hepatitis A, B and/or C option
(Participants outside Australia)
3x5
825.00
660.00
HEPM4310fHepatitis Serology - Hepatitis A, B and/or C option
(Participants outside Australia)
3x10
1,125.00
900.00
HEPM4310fHepatitis Serology - Hepatitis A, B and/or C option
(Australian participants only)
3x10
560.00
NA
(Australian participants only - No charge)
3x10
NA
NA
3x5
550.00
440.00
(No charge to Australian participants)
3x10
750.00
600.00
3x5
550.00
440.00
3x10
750.00
600.00
Syphilis Serology
3x5
550.00
440.00
TREP4310 Syphilis Serology
3x10
750.00
600.00
TORC435
Toxoplasma, Rubella and CMV serology
3x5
550.00
440.00
CMVN435
CMV DNA Qualitative and Viral Load
3x5
975.00
780.00
CTNG435
C.trachomatis | N.gonorrhoeae DNA Qualitative
3x5
975.00
780.00
HAPN435
HAV RNA and Parvovirus B19 DNA Qualitative and Viral Load
3x5
975.00
780.00
HBVL435
HBV DNA Viral Load
3x5
975.00
780.00
HCVG435
HCV Genotyping
3x5
975.00
780.00
HCVL435
HCV RNA Viral Load
(No charge to Australian participants)
3x5
975.00
780.00
HCVN435
HCV RNA Qualitative
(No charge to Australian participants)
3x5
975.00
780.00
HIVL435
HIV-1 RNA Viral Load
(No Charge to Australian participants)
3x5
975.00
780.00
HIVG425
HIV-1 Genotypic Drug Resistance
2x5
1,800.00
1,440.00
HSVN435
HSV-1/2 DNA Qualitative
3x5
975.00
780.00
HEPM4310fHepatitis Serology - HCV only option
HIVC435
HIV Serology
HIVC4310
HIV Serology
HTLV435
HTLV Serology
HTLV4310 HTLV Serology
TREP435
(No charge to Australian participants)
Total
(AxC)+B
PROGRAM TOTAL $
Office Use Only
Shipping and handling fees are additional and will be included in your invoice. Shipping estimates available on request. SHIPPING AMOUNT
$
Australian participants only. GST
$
PAYMENT AMOUNT
$
*Extra panels of samples can be purchased at 50% of the program's price. There is a limit of one additional program per customer. This option is not available for HIVG425
Office Use Only Test Events:
Special Requirements:
Distributor Code:
Serology
TE1
TE2
TE3
W HO
MTA
ACCESS
Other
Serology
NAT
TE1
TE2
TE3
Program
NAT
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