GEMS Order Form

Mailing Address: University of California, Berkeley GEMS Lawrence Hall of Science #5200 Berkeley, CA 94720-5200	To order by phone or fax: Phone (510) 642-7771 Fax (510) 643-0309
Name ______________________________________ Address_____________________________________ ___________________________________________ City________________________________________ State__________________Zip___________________ Phone ______________________________________	Billing Address (If different from shipping) ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________

Item Name	Quantity	Unit Cost	Total Cost

Shipping Charges and Taxes: Please calculate shipping charges and taxes based on the guidelines posted at www.lhsgems.org/orderinfo.html

Payment Information Check#__________________ PO #______________________ Organization FEIN# (required for use of a PO): _____________________________________ Credit Card Information: Number:__________________________________ (MC, Visa, Discover — circle one) Expiration Date:__________________ Signature:________________________________

Subtotal_____________________ CA Tax_____________________ Shipping____________________ Total_______________________ Please make checks to: Regents of the University of California.