<p> Custom DNA Oligos Fax Order Form</p><p>Please complete this form and fax it back to Eurofins Genomics: UK: +44-1902-693-286; France: +33-1-69-10-88-84; Rest Europe & ROW: +49-8092-21084 Note: Max. 10 oligos per fax order. Please do not email this form. Application oligos can only be ordered online.</p><p>Contact Details</p><p>Your Delivery Address: Your Invoice Address: First & Last Name: Institute / Department: University/Company.: Street: Postal Code / City: Country: Phone / Fax: Email: Customer ID:</p><p>Order Ref. No.: Quote-No.: Delivery Service: Express Standard (for Germany only) VAT Exempt (UK only): Yes* No VAT-No. (EU only): * Please provide VAT exemption certificate</p><p>Oligo Order</p><p>No. Oligo Name: Synthesis 0.01 0.05 0.20 1.00 10.0 (max.15 characters) Scale [µmol]:</p><p>Modification Purification Level Quality Documentation 5’: 3’: Intern: Salt Free HPSF HPLC HYPUR Yes No</p><p>5’ 3’</p><p>No. Oligo Name: Synthesis 0.01 0.05 0.20 1.00 10.0 (max.15 characters) Scale [µmol]:</p><p>Modification Purification Level Quality Documentation 5’: 3’: Intern: Salt Free HPSF HPLC HYPUR Yes No</p><p>5’ 3’</p><p>No. Oligo Name: Synthesis 0.01 0.05 0.20 1.00 10.0 (max.15 characters) Scale [µmol]:</p><p>Modification Purification Level Quality Documentation 5’: 3’: Intern: Salt Free HPSF HPLC HYPUR Yes No</p><p>5’ 3’</p><p>No. Oligo Name: Synthesis 0.01 0.05 0.20 1.00 10.0 (max.15 characters) Scale [µmol]:</p><p>2014-03-14 1 Custom DNA Oligos Fax Order Form</p><p>Modification Purification Level Quality Documentation 5’: 3’: Intern: Salt Free HPSF HPLC HYPUR Yes No</p><p>5’ 3’</p><p>No. Oligo Name: Synthesis 0.01 0.05 0.20 1.00 10.0 (max.15 characters) Scale [µmol]:</p><p>Modification Purification Level Quality Documentation 5’: 3’: Intern: Salt Free HPSF HPLC HYPUR Yes No</p><p>5’ 3’</p><p>No. Oligo Name: Synthesis 0.01 0.05 0.20 1.00 10.0 (max.15 characters) Scale [µmol]:</p><p>Modification Purification Level Quality Documentation 5’: 3’: Intern: Salt Free HPSF HPLC HYPUR Yes No</p><p>5’ 3’</p><p>No. Oligo Name: Synthesis 0.01 0.05 0.20 1.00 10.0 (max.15 characters) Scale [µmol]:</p><p>Modification Purification Level Quality Documentation 5’: 3’: Intern: Salt Free HPSF HPLC HYPUR Yes No</p><p>5’ 3’</p><p>No. Oligo Name: Synthesis 0.01 0.05 0.20 1.00 10.0 (max.15 characters) Scale [µmol]:</p><p>Modification Purification Level Quality Documentation 5’: 3’: Intern: Salt Free HPSF HPLC HYPUR Yes No</p><p>5’ 3’</p><p>With this order I accept the General Terms and Conditions of Sale (GTCs from 01.04.201) of Eurofins Genomics GmbH.</p><p>2014-03-14 2</p>