Order Samples and Literature

Please take time to complete the following form and click on the submit button when completed.
All fields markers with an * are compulsory.

Your details
Title:
Name:	*
Company:	*
Address:	*
City/Town	*
County/State	*
Postcode/ ZIP	*
Country	*
Telephone:
Fax:
Email:	*
Job Title:		Other

Information
Please send me information on:	Preferred method of contact
New Products	Email
Sales Promotions	Fax
Training Courses	Phone
Visit by your representative	Post


Literature Please send me the following literature
Chromacol Select	HPLC Mobile Phase Handling
Column Block Heater	HPLC Catalogue
Chromatography Data System	HPLC Training Courses
Chromacol 2004 Catalogue	Life Sciences Catalogue
Detector Lamps	Syringe Filters
Generic Guard Column	Microsampling
Webseal Brochure	CTC Brochure
Samples Please send me the following samples:
Optional Questions If you have the time, please complete the following questions. If not, then just click on the submit button at the bottom of this form, and your samples / literature will be sent shortly.

I work in the following fields:
Biotechnology	Environmental
Chem/Petrochemical	Food/Beverage
Clinical/Hospital	Pharmaceutical
Education	Other

The following autosamplers are used in my departmet.
Agilent/HP	Shimadzu GC
Beckman	Shimadzu LC
CTC Analytics	ThermoQuest GC
Fisons	ThermoQuest LC
Gilson	Varian GC
Jasco	Varian LC
Merck/Hitachi	Waters 48
PE GC	Waters 96
PE LC	Others
Model Numbers:

Current Consumables Supplier:
Annual Usage of vials:
Approximate annual spend on HPLC consumables:
Do you plan to work with micro titer plates ?	Yes No
Would you like to be contacted by Chromacol for marketing purposes?	Yes No
Would you like to be contacted by any carefully selected third parties ?	Yes No
Thank you for taking the time to complete this form, your samples/literature will be sent to you shortly.