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Figure G: Pro Forma Invoice

Ship to:

Quest Diagnostics Nichols Institute of Valencia
27027 Tourney Road
Valencia, CA 91355
U.S.A.

Shipped from: _____________________________ to Los Angeles, CA, U.S.A.

On Date: _____________________________
Airline: _____________________________
AWB #: _____________________________

Number of Packages: _____________________________
Weight of Shipment: _____________________________

Description of Contents Quantity Declared
    $
    $
    $
    $
    $
    $
Totals:   $

Contents have no commercial value. Declared value is for customs purposes only. Contents are human blood/serum specimens for diagnostic purposes only.

Shipper:

_________________________________________
_________________________________________
_________________________________________
_________________________________________

I, the undersigned, declare all the information above correct to the best of my ability.

_________________________________________
(shipper)






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For test information, please call Client Services at 800-421-4449.

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