ࡱ > c e b bjbj aO z z J J J J J $ n n n n $ n t ^ t t t t B D D D D D D , ? h p J " p J J t t a J t J t B B =[ . 0 Y Y J p p p Y z : HHMI / Keck Biotechnology Resource Laboratory Non-Yale Biostatistics Resource Submission Form Order Date:MMDDYYYour Name:Last NameFirst NameMIPI Name:Last NameFirst NameMI Department:Institution: Telephone:( ) -Fax:( ) -E-mail: PI E-mail: Billing Address: (Required)Street AddressCity, StateZip CodeShipping Address: Street AddressCity, StateZip Code Required Charging Instructions (Check one):P.O. Number-Amount:$HHMICredit Card Enter a Purchase Order Number above and indicate whether the charging instructions refer to a P.O. Number, or an HHMI P.O. Number. Indicate P.O. Amount, if applicable. If paying with a credit card, please complete the form at: HYPERLINK "http://medicine.yale.edu/keck/about/admin/invoicing.aspx" http://medicine.yale.edu/keck/about/admin/invoicing.aspx