CHTM Chemical Order Form

Please fill out the form to place a chemical order. If this form is submitted and is incomplete, your order will NOT be processed.

Name:
E-mail:
Vendor:
Vendor Phone:
Lab Number:
PI:
Index Number:
Business Purpose:

Chemical Information
Description/Details: Catalog: Quantity: Unit size: Unit cost:
Description/Details: Catalog: Quantity: Unit size: Unit cost:
Description/Details: Catalog: Quantity: Unit size: Unit cost:

Is this a consumable or chemical?
Consumable Chemical
Is this a reorder?
Yes No
Is there a current SDS?
Yes No