BioFire POC Fuse Box Program

To review the complete POC Fuse Box Program outline please click here.

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Contact Information
Your Name*
First Last
Sales Territory (Region & Number)*
Legal Name of Company/Institution*
Primary Contact*
Email Address of Primary Contact*
Phone Number*
Is this order for a teaching hospital?*
- Yes
- No
If yes, please provide the hospital's Tax Identification Number (TIN):*
Does the customer need a No Charge P.O.?*
- Yes
- No
If yes, please provide the No Charge P.O. number:*
Name of FAS doing installation:
Shipping Information
Customer/Company Name*
Address*
Attn: Address Line 2 City State / Province / Region ZIP / Postal Code Country
Desired Date for Arrival
MM slash DD slash YYYY
Reason if expedited shipping is required
*Manager approval needed*
Special Instructions, if any
Fuse Box Items
Prices listed are the amounts taken out of your Fuse Box funds.
Universal Power Supply (SMT1500) Quantity
Price: $478.99
QC Material (CHEM-CTL-0001) Quantity
Price: $342.00
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