**NIA AGED RODENT TISSUE BANK ORDER FORM**

Order desk: FAX 301-402-5997 Phone 301-496-0181 email:
[rodents@nia.nih.gov](mailto:rodents@nia.nih.gov?subject=NIA Aged Rodent Tissue Bank Order Form)

For billing and invoicing questions, contact Sandy Butt, BioReliance,
301-610-2510

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  BRB Office Use Only     NIA Confirmation Number  

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Provide **[all]{.underline}** information. Orders must be received by
**[noon]{.underline} Tuesday (ET)** for following week delivery.

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  Principal                             
  Investigator's                   
  Name:                            

  Institution:                     

  Shipping                         
  Address:                         

                                   

                                   
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  ------------ ----------------------------------------------------------
  Billing           
  Address:     

                    

                    
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  Contact                                                                
  Person's                                                               
  Name:                                                                  

  FAX:                            Phone:                        Email:        

  Accounts                                                               
  Payable                                                                
  Contact                                                                
  Person's                                                               
  Name:                                                                  

  FAX:                            Phone:                        Email:        
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  P.O. \# :                                 Delivery        
                                            date:      

  Name of                                              
  project:                                             

  Funding                                              
  agency and                                           
  grant                                                
  number:                                              
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  ----------- ---------- --------------- ------- -------- ----------- ---------------
  BRB use:\   Quantity   Strain          Age     Gender   Tissue      Additional
  t=tumor                                (mo.)                        Information
  nt=non                                                              
  tumor                                                               

                                                                           

                                                                           

                                                                           

                                                                           

                                                                           

                                                                           
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  Special Instructions:         if tissue must be from tumor free animals.
  Check here                    

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