FAX GABA ASSAY FORM TO:      207-422-6830

Name:

_________________________________       ______________________________

First                                                    Last

Date:

____________________

Phone:

____________________

Email:

______________________________________

Billing Address:

____________________________________________________________________     Grant # to charge:___________________

Street Address

_____________________________________________________________________

Address Line 2

_______________________________________  _____________________________

City                                                           State/Province/Region

_______________________________________  _____________________________

Zip/Postal Code                                       Country

Have you emailed Excel or Numbers GABA sample list file to Quantify@Mitokine.com?_____ Yes/No

Plasma or serum samples?___________ Other:__________________________

Number of samples:__________________

Date overnight shipped:_______________

Shipping Address:

Mitokine Bioscience, LLC

13 Captain Bill Rd. Ste 1 Tamarack Pl.

Hancock, ME 04640