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Free Product Claim Form PDF Print E-mail
Wednesday, 25 April 2012 00:00

 LSU Product Claim Form Banner

How to claim your FREE product:

Step 1: Enter how many product lines you would like to claim (NOTE: please use a separate form for each supplier)
Step 2: Enter your contact information including your Lab Start-Up account number (6 digits, starts with "66")
Step 3: Enter the details of each FREE product you would like to claim
Step 4: You will be asked to tick the box to show that you have read the Terms and Conditions

If you have a FISHERBRAND voucher to redeem please use this form »

All fields marked with a *(red asterix) are mandatory to complete the form.
Please enter your full company details. Do not enter your residential address as we only deliver to business addresses. Thank you.

Product Details
Number of product lines you would like to claim:
NOTE: please use a separate form for each supplier		 *

Customer Details
Title:
First name: *
Surname: *
Email: *
Job title:
Company name: *
Account number:
Ship to:
Department:
Address street: *
Address:
Address (Area):
Address (post town): *
Postcode: *
Country:
Telephone:
Extension:
Fax:

Additional Information
House name / Building details:
School / Institute (e.g. Medical School):
Number of Scientists on site?:
How many people on your
site require safety equipment?:

Communication Mechanisms
Add me to mailing list? Prefer telephone
Prefer mail Prefer email
Prefer faxNo promotional contact

Verification
What is the day after monday: *
 

 
Last Updated on Wednesday, 25 April 2012 16:33