ADDITIONAL KITS / MATERIAL ORDER FORM
FOR UNITED STATES, CANADA AND PUERTO RICO

Remember my personal info for future forms.

A check or tick mark in this box will save you time in the future, when you request information from the Covance web site. A cookie file will be placed on your computer that allows our web site toauto-fillyour commonly used name and contact fields on our forms. If you wish to change any of the auto-fill information, simply type your new information over the previous auto-filled entry or entries on the form, and click the submit button. The previous information will be updated with the new. If you do not want to use the auto-fill feature, or have a cookie placed on your computer, simplyuncheckthe box and the cookie information will be purged.

*Pharmaceutical Sponsor:

*Requestor's First Name:

*Requestor's Last Name:

*Complete Protocol Number:

Please include all alpha/numeric characters.

Covance Project Number:Please include your Project Number!

*Principal Investigator First Name:

*Principal Investigator Last Name:

*Site Number:

*Country:SELECT COUNTRYAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBenin百慕大BhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundi柬埔寨CameroonCanadaCape VerdeCayman Islands中非RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic Republic of theCook IslandsCosta RicaCote D'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island and Mcdonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsraelItalyJamaicaJapanJordan哈萨克斯坦KenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, the Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanama巴布新几内亚ParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTonga特立尼达和多巴哥TunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.s.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe

*Phone Number:

*Email Address:

*Confirm Email Address:

View Standard and Expedited Delivery Timeline Chart

• Orders requiring Sponsor approval may extend the delivery date.
• Due to regional holiday and transit schedules, actual delivery dates may be within 3 business days of the date indicated.

*Standard Delivery
Please refer to chart for estimated delivery timelines.

*Expedited Delivery
Please refer to chart for estimated delivery timelines. Expedited orders incur an additional fee ($87.35 USD) and additional shipping and handling when applicable. Expedited shipments may require sponsor approval prior to order entry.

Remember my last order request (section B).

Checking this option will bring in the last order contents for each new order request. If you do not want to use the auto-fill feature, or have a cookie placed on your computer, simplyuncheckthe box and the cookie information will be purged.

Lab Kit