ChemPep Order Form

Please fill in the form to place your order ( * indicates required information).

Purchase Order #:
Quotation #:
Date (mm/dd/yy): *
First Name: *
Last Name: *
Company/University: *
Telephone: *
E-mail: *
Attention To: *
Shipping Address: *
City: *
State/Province: *
Zip/Postal Code: *
Country: *
Billing Address: *
(same as shipping address)
City: *
State/Province: *
Zip/Postal Code: *
Country: *

Unit Size
Catalog #
Product Description
Unit Price (US $)

Shipping Terms

Payment Type

  • To pay by check, please make it payable to ChemPep, Inc., and send it to our mailing address.
  • To pay by wire transfer, please contact us for our bank information.
  • To pay by credit card, please call us or fax to us the following information: (1) card type, (2) card number, (3) name on card, (4) expiration date, (5) CVV number, (6) credit card billing address. We accept all major credit cards (Visa, MasterCard, American Express and Discover). You may use our credit card payment form (in PDF format).

  • Special instructions/Comments (optional)..

    Notes: All ChemPep products are sold for Research & Development use only. They are NOT intended for drug, household or any other uses. All products must be handled by professional staff or qualified individuals experienced in handling potentially hazardous chemicals. We will reject orders from private individuals not affiliated with an organization. We reserve the right to insist on a written order and/or references before proceeding with an order. The buyer may be asked to provide a written assurance that products not be purchased/resold for an improper use.