For Office Use Only s19

ORDER FORM

McGill University Exemption under Section 56 List your Authorization #

______1. This form must be completed and signed by an Signature: ______individual legally empowered to take custody of these products. ______

2. Send all correspondence to: Print name: EDR McGill University, CMARC Emergency Drug Release 3655 Pr. Sir-William-Osler List your EDR # Montréal, QC H3G 1Y6 ______Att: Rosanna RM 1440

DVM Licence For lab animal research only.

Date: ______

PAYMENT OPTIONS Card Your Credit Card information will be requested separately holder when your order is ready to be sent. name:

MasterCard Telephone: Visa E-Mail: Purchase order Please send a copy of the Purchase Order with this order form. PO#: UVic AGR01732 Purchase order must contain billing and shipping information. FAST Account #______FOAPAL#: FOAPAL (Internal McGill/MUHC only) Department:

SHIPPING METHOD SHIP TO Pick-up (Please note, if you pick-up you may pay University of Victoria Science Stores with credit card in person) 3800 Finnerty Road, Petch Building Room 168 Ship (Please provide shipping information)  Victoria, BC V8P 5C2 For Exemption 56 Authorization, drug orders will be shipped to the address listed on your [Contact person for shipping] authorization letters. Please give Contact, e- [e-mail] mail and telephone #. [Phone]

QTY DESCRIPTION SIZE UNIT PRICE Buprenorphine 0.3 mg/ml 1 ml vial 9.00 Pentobarbital 54.7 mg/ml 100 ml bottle 118.00 Ketamine 100 mg/ml 10 ml vial 105.00 Euthanyl 240 mg/ml 250 ml bottle 70.75 Euthansol 340 mg/ml 250 ml bottle 83.00 Subtotal to be billed or charged, amount before shipping, handling and applicable taxes $______

For office use only SALES ORDER CREDIT CARD SHIPPING DELIVERY DATE REFERENCE # AUTHORIZATION #

CMARC updated September 1, 2012