Chess User Shipping Form

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CHESS User Shipping Form
Ship to address:
Name:
_________________________________________________________________
Phone #:
_________________________________________________________________
Institution:
_________________________________________________________________
Address:
_________________________________________________________________
(Include Dept./Floor/Suite or Room #)
Address:
_________________________________________________________________
City:
____________________________ State/Province: _______________________
Zip:
___________________________ Country: ____________________________
Ship via:
UPS
FedEx
Airborne
[ ] Overnight (Priority)
[ ] Overnight
[ ] Next-Day Air
[ ] Overnight
[ ] 2-Day
[ ] Regular Air (3 days)
(Standard)
[ ] 2-Day
[ ] Ground
Method of payment:
[ ] Pre-paid
[ ] Carrier account: _______________________________
[ ] Credit Card Type of Card (VI, MC, DS) ________ Card #: ________________________________
Exp. Date:_____________________
[ ] CHESS Proposal #: _______________
[ ] Use Own Shipping Form attached
Shipment must arrive by: __________________
Weight of Package:_________________________
Insurance: [ ] none
[ ] declare $_______________
Dimensions: _______L X _______ H X ________W
Contents of Package (if Hazardous please contact Kathy Dedrick before shipping):
______________________________________________________________________________________
______________________________________________________________________________________
If Shipping a Dewar:
Additional Shipping Comments:
[ ] Dewar is Dry
[ ] Dewar needs to be emptied
[ ] Dewar must be shipped w/Liquid Nitrogen
Name of Person Completing Form:____________________________________________________
Date:__________________________

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