ALine, Inc. 2206 E. Gladwick St., Rancho Dominguez, CA 90220
Phone: 877-707-8575 Fax: 770-818-5475 email: sales@alineinc.com
This is not an online order form. You may type your information in to this form, print it out and faxed or mailed it to ALine, Inc.
Contact Information/Ship to address
Name
Company
Address
Address 2
City
State/Country
Zip_ Code/Postcode
Phone number
Alternate phone number
Fax number
email address
Bill to
check if billing address is the same as contact address
Name
Company
Address
Address 2
City
State/Country
Zip_Code/Postcode
Payment Information
Credit Card #
Card Type
Name on Card
Expiration Date
Card Verification Code   
I would like the following items
Qty Description

Custom Bio Micro Cuvette Ordering Table
Choices Type (click to open an ordering selector guide pdf)
Windows Type
Adhesive Type
Body Material & Thickness
Port Type
Port Location
Membrane & Location
       Location
       Material
Bead Retension Mesh
Comments
FAX your order to: 770-818-5475
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