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Purchase Order for French Pharmacopoeia Reference Standards Direction des Contrôles

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Direction des Contrôles

CS60007, 34748 Vendargues Cedex (FRANCE)

Tél : + 33 (0)4 67 06 46 84 / + 33 (0)4 67 06 46 83 / + 33 (0)4 67 06 46 00 Fax : + 33 (0)4 67 06 46 97

Mail :

Purchase Order for French

Pharmacopoeia Reference Standards

RÉPUBLIQUE FRANÇAISE

143/147 boulevard Anatole France - F-93285 SAINT-DENIS Cedex – FRANCE - Tél.: +33 (0)1 55 87 30 00 - www.ansm.sante.fr

Your purchase order reference number:

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Full billing address:

City:

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Contact name:

Tel: Fax:

email:

SHIPPING ADDRESS

(only if different from billing address) Company name:

Full shipping address:

City:

Postal code:

Country:

Contact name:

Tel: Fax:

email:

Reference standard name (catalogue number)

Quantity (Price per unit : 45€

inclusive of tax)

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Date: Total amount in €

(inclusive of tax)

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