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FACSIMILE TRANSMITTAL SHEET
To: PAMAM Sales FAX Number: +61 3 9510 5955
From: Organisation:
Email: Date:
Purchase Order Number:
CREDIT CARD CHARGE AUTHORITY
I hereby authorize Dendritic Nanotechnologies, Inc. to charge my credit card as follows for the purchase of PAMAM dendrimers.
Amount in US Dollars: US$
Credit Card Type (please circle): Visa Mastercard
Credit Card Number:
Cardholder name
(as it appears on your card):
Security Code (last 3 digits on back / 4 on card front):
Expiry Date:
Signature:
Date:
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