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		Online Order Form Please provide the following information:

Contact Information

Name*

Tel*

Address

Company/Institution

Email*

Fax

End User Details if not as above

Important

In order to comply with export control regulations please state your use of Klarite products

Industrial Chemical

Pharmaceutical

Medical

Academic/Research

Forensics

Environmental

Police/Military

Nuclear

Chemical/Biological agents

Other

Equipment to be used for Raman Analysis

Manufacturer

Model Number

Laser Wavelength

Detection Area

Product

Quantity

302	Microscope slide mounted Klarite Surface enhanced Raman substrate (min quantity 5)
303	Unmounted Klarite Surface enhanced Raman substrate (min Quantity 5)
306	SCal Raman silicon calibration standard (min quantitly 1)
	Customised product (please contact D3 Technologies)

Details of chemical(s) to be tested

Any other special requests

Where did you hear about Klarite products?

Website
Conference
Advertisement
Colleague
Technical Paper
Other

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