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<col style="width: 3%" />
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<col style="width: 9%" />
<col style="width: 13%" />
<col style="width: 3%" />
<col style="width: 8%" />
<col style="width: 12%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="2"><img src="media/image1.wmf" /></td>
<td colspan="5"><p><strong>Ernest Orlando Lawrence</strong></p>
<p><strong>Berkeley National Laboratory</strong></p></td>
<td colspan="4"><p><strong>Fisher Scientific Fax Order Form</strong></p>
<p><strong>www.fishersci.com</strong></p></td>
<td colspan="2"><p><strong>Fax To:</strong></p>
<p><strong>Fisher Scientific</strong></p>
<p><strong>1-800-926-1166</strong></p></td>
</tr>
<tr class="even">
<td colspan="4"><strong>LBNL / Vendor Information</strong></td>
<td colspan="9"><h1 id="fisher-customer-service-866-374-8225">Fisher
Customer Service 866 374 8225</h1></td>
</tr>
<tr class="odd">
<td colspan="4">Supplier</td>
<td colspan="9"></td>
</tr>
<tr class="even">
<td colspan="4">Fisher Scientific</td>
<td></td>
<td colspan="8"><strong>Requester / Delivery Information</strong></td>
</tr>
<tr class="odd">
<td colspan="4">Fisher Acct # No. 114816-014</td>
<td></td>
<td colspan="3">Requested By</td>
<td>Employee #</td>
<td>Project ID #</td>
<td colspan="2">Phone No. (510)</td>
<td>Fax No. (510)</td>
</tr>
<tr class="even">
<td colspan="4"><p>MATERIAL SCIENCES DIVISION</p>
<p>P.O. #6706893</p></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td></td>
<td colspan="3">Deliver To (Name)</td>
<td></td>
<td>Building</td>
<td colspan="3">Room</td>
</tr>
<tr class="even">
<td colspan="4"><strong>Ship to:</strong></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="4"><p>Lawrence Berkeley National Laboratory</p>
<p>1 Cyclotron Rd, Bldg. 69</p>
<p>Berkeley, CA 94720</p></td>
<td></td>
<td colspan="8"></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td></td>
<td>UOM</td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td>(each, pack</td>
<td colspan="7">Description &amp; Cost Per Unit</td>
</tr>
<tr class="even">
<td>Item</td>
<td colspan="2">Catalog Number</td>
<td colspan="2">Quantity</td>
<td>or case)</td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td>1</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td>2</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td>3</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td>4</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td>5</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td>6</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td>7</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td>8</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td>9</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td>10</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="7"></td>
</tr>
</tbody>
</table>

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