Immunology Core QDot™ Reagent Request

* CFAR Principal Investigator

* Institution

* NIH grants supported (ex- R01 AI065987)

REAGENTS REQUESTED

A single 50 test aliquot will be provided at no charge for testing in your panel.

CD4-Qdot™605 number requested

100 tests ($75)

50 tests (no charge)

CD4-Qdot™655 number requested

100 tests ($75)

50 tests (no charge)

CD8-Qdot™605 number requested

100 tests ($75)

50 tests (no charge)

CD8-Qdot™655 number requested

100 tests ($75)

50 tests (no charge)

Purchase Order (Optional)

* Billing Address:

Checks and Purchase Orders payable to:

Beth Israel Deaconess Medical Center

CFAR Immunology Core/CLS 1042

330 Brookline Avenue

Boston, MA 02215

Attn: Kristine Regione

* SHIPPING

Will pick up at BIDMC, CLS-3 Blackfan Circle

Deliver via FedEx

FedEx Account #

DELIVER TO:

* Name

* Email Address

* Address:

* Phone

For questions, contact Keith Reimann at 617-735-4476or kreimann@bidmc.harvard.edu

* Indicates Response Required