ORDER FORM PLEASE ALLOW A MINIMUM 2 WEEKS LEAD TIME FOR ALL ORDERS Medical & Clinical Consortium 6880 Oran Circle Suite G Buena Park, CA 90621 Phone: 714-367-2284 Fax: 714-367-2285

Note: If you do not find the combination you are looking for, please contact the Office. FORM

*REQUIRED

*DATE: 00 01 02 03 04 05 06 07 08 09 10 11 12 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 0000 2005 2006 2007 2008 2009 2010 2011 2012   *P.O. NUMBER: *ORDERED BY:

*BILL TO: *ADDRESS:

*CITY: *STATE: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *ZIP:

*PHONE: FAX: EMAIL:

Please indicate Method of Payment: Payment with Credit Card   Other

***You will be notified when your your order is received. Your Credit Card information will be obtained at that time.

DROP SHIP INSTRUCTIONS: SHIP VIA CARRIER: (Distributors must fill-in to ship to your costomer via UPS, FEDEX, etc.)   SHIPPING COMPANY: YOUR SHIPPER ACCOUNT NO:

SHIP TO: (UPS will not ship to a P.O.Box) PHONE: FAX:

ADDRESS:   COMMERCIAL BLDG: RESIDENCE:

CITY: STATE: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP:

*For Special Orders, Extra Lead-Time is Required and Minimum Quantities Apply.

Single Tests Choose Cassette or Dipcard Item Number
Cassette			Min. Qty		Assay	Qty Ord
	1301		50		Amphetamines
	1302		50		Barbiturates
	1303		50		Benzodiazepines
	1304		50		Cocaine
	1305		50		Marijuana
	1306		50		Methamphetamines
	1307		50		Opiates
	1308		50		Phencyclidine
	1311		50		Methadone
	1312		50		MDMA ”Ecstasy”

Multi-Panel Tests
Ca-Dip & Dip Cards Choose Ca-Dip or Dip Card Item Number
Ca-Dip			Min. Qty		Assay	Qty Ord
	2301		50		COC ,THC
	2302		50		M-AMP, THC
	3301		50		COC ,THC, M-AMP
	3303		50		COC, THC, OPI
	3303		50		COC, THC, AMP
	4301		50		M-AMP, COC, THC, OPI
	5301		50		COC, AMP, M-AMP, THC, OPI
	5302		50		COC, M-AMP, THC, OPI, PCP
	5303		50		COC, AMP, THC, OPI, PCP

ECO Cups (New self contained drug testing cups)
Cups Choose Item Number
Item #			Min. Qty		Qty Ord
	5401		50	5 - Panel Eco Cup (AMP, COC, THC, M-AMP, OPI)
	5402		50	5 - Panel Eco Cup ( COC, THC, M-AMP, OPI, PCP)
	5403		50	5 - Panel Eco Cup ( AMP, COC, THC, OPI, PCP)

ECO II Cups (New self contained drug testing cups)
Cups Choose Item Number
Item #			Min. Qty		Qty Ord
	5201		50	5- PANEL ECO II CUP (AMP , COC, THC, M-AMP, OPI)
	10201		50	10-PANEL ECO II CUP (AMP BAR, BZO, COC, THC, M-AMP, OPI, PCP, MTD, MDMA)

Other Items
Additional Items Choose Item Number
Item #			Min. Qty			Qty Ord
	9914		50	CUP W/SCREW LID & TEMP. STRIP. (AVAIL.W/TEST ONLY)
	9916		50	SPECIMEN CUP (STERILE) W/SCREW LID & TEMP. STRIP. (AVAIL.W/TEST ONLY)