Fax this custom peptide quote request to Biopeptide  1-858-657-9440

Date:________ Purchase Order#:______________Number of Peptides:______

Institution:_________________________________________________________

End User Name:______________________ Purchasing Agent:_______________

Phone:_________________ Fax:__________________ E-mail:_______________





Ship To Address: _______________________________________________

                 _______________________________________________

Bill To Address: _______________________________________________

                 _______________________________________________





Peptide 1 Name:  ____________________________________________________



N-term-____-____-____-____-____-____-____-____-____-____-____-____-

       ____-____-____-____-____-____-____-____-____-____-____-____-

       ____-____-____-____-____-____-____-____-____-____-____-____-

       ____-____-____-____-____-____-____-____-____-____-____- C-term 





N-terminus:             Amine    Acetyl(Blocked)      (circle one)

C-terminus:             Acid     Amide(Blocked)       (circle one)

Quantity:   5mg 10mg 15mg 20mg 25mg 30mg 50mg 100mg   (circle one)

Other Quantity: _____________ mgs

Purity:         >75%    >90%    >95%    >98%          (circle one)---



Peptide 2 Name:  ____________________________________________________

N-term-____-____-____-____-____-____-____-____-____-____-____-____-

       ____-____-____-____-____-____-____-____-____-____-____-____-

       ____-____-____-____-____-____-____-____-____-____-____-____-

       ____-____-____-____-____-____-____-____-____-____-____- C-term 





N-terminus:             Amine    Acetyl(Blocked)      (circle one)

C-terminus:             Acid     Amide(Blocked)       (circle one)

Quantity:   5mg 10mg 15mg 20mg 25mg 30mg 50mg 100mg   (circle one)

Other Quantity: _____________ mgs

Purity:         >75%    >90%    >95%    >98%          (circle one)---



Mass Spectral Analysis and HPLC trace always included:




Other Modifications or requests:_____________________________________

_____________________________________________________________________

Quotation#_________ (Leave blank) Acknwg/Order# _______ (Leave Blank)

Biopeptide Sign.______________ Customer Signature____________________

Price (US Dollars):_____________ + _______ shipping =________________