FAX completed form to 310-222-3432 or EMAIL to "parlow@humc.edu"
Direct any questions to A.F. Parlow at VOICE: 310-222-3537 or 310-415-2994

1. NHPP Account Number:                                      (Optional)
                        (if known)           FedEx Acct# : _______________________
   Full Name:                                FedEx Internal Billing #: ___________
   Shipping Address:                         
   (Do NOT use P.O. Box. Use Building name,  Credit Card Type: ___________________
    street address, room number only)        
                                             Credit Card #: ______________________
                                             
                                             Credit Card Exp. Date: ______________

                                             Purchase Order #: ___________________

                                             Billing Address:  ___________________

                                                               ___________________


   City__________________  State_____  Zip_________  Country_______________

   VOICE:(___)______________ FAX:(___)______________ E-MAIL:_______________


2.  Reagent Request:

    a) Complete RIA Kits:







    b) Other Reagents [not listed in a)]:

* For Hormone, please specify if Biological (B), Reference (R), or
  Iodination (I).

**For Antisera, please specify if Radioimmunoassay (RIA), or
  Immunocytochemistry (IC).


3.  Research:  BRIEFLY describe the proposed use of the reagent(s)
    you are requesting, to justify the kind(s) and amount(s) being used.








4.  Acknowledgement:

    In publications which have utilized Reagents from the NHPP, the 
    Investigator is welcome to acknowlege the Program in the Materials and 
    Methods Section of the publication. A suggested form of acknowledgement is 
    (Reagent name, Lot #) was obtained from the National Hormone & Peptide
    Program (NHPP), NIDDK, and Dr. Parlow.


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            Signature                                    Date

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            Printed name