TO BE PRINTED ON CUSTOMERS COMPANY LATTERHEAD (Please delete this line

before print)

POISON SIGNED ORDER

To

From

Matrioux (M) Sdn Bhd

B-1-36, Kompleks Suria Kinrara,
Persiaran Kinrara Seksyen 3,
Taman Kinrara,
47100 Puchong. Selangor DE.
Tel: 03-8080 2070
Fax: 03-8075 2070

AIMST University
Department of Biotechnology
Jalan Semeling
08100 Bedong
Kedah Darul Aman
PO Number: PO00000356
PO Date: 26/12/2014

Please supply the followings:

N
Product
Product Name
o.
Code
BLN#BIO- TRIsure 100ml
1
38032

Pack
Size
100ml

Quant
ity
1.00

Purpose of which
required

2
3
4
5
6
7
8

IMPORTANT
This Original Poison Signed Order MUST BE SENT to Matrioux (M) Sdn Bhd
within 7 days with complete details of Purpose of Purchase, official
Company Stamp and Signature with Purchasers Name.
Any purchaser who fails or neglect to forward to the seller
___________________________________________________
a written order duly signed by him shall be guilty of an
and Signature of Chemical User/Purchaser

Companys Stamp

offence against the Poison Act 1952.

Name: