PABIL INSECT REQUEST FORM

First Name:

Last Name:

Organization:

Email Address:

Email Address to send invoice to if different than above:

Phone Number:

Shipping Address: Street, City, Zip

Billing Address if different than shipping Street, City, Zip

Setting for use of the insect: Check all that apply

Homeowner

Farmer

State or County

Federal

University

Other

Please specify

Insects interested in: Check all that apply

Quantity interested in: Epilachna varivestis

Quantity interested in: Halyomorpha halys adults

Quantity interested in: Halyomorpha halys egg masses

Quantity interested in: Halyomorpha halys nymphs

Permit Holder’s Name:

Permit Number:

Permit Expiration Date:

Shipping Method: (if you prefer that we use your account to cover shipping charges)

UPS

FedEx

Clear

Shipping Account Number:

Quantity interested in: Hypena opulenta caterpillars

Quantity interested in: Hypena opulenta moths

Quantity interested in: Hypena opulenta pupae

Quantity interested in: Lygus hesperus egg pack

# of units interested in: Lygus hesperus nymphs

# of units interested in: Pediobius foveolatus adults

# of units interested in: Pediobius foveolatus larvae (mummies)

Quantity interested in: Rhinoncomimus latipes adults

Orders are accepted on a first come, first served basis, please choose 3 preferred shipment dates. They must be different weeks.

Week 1

Week 2

Week 3

Shipping Method: (if you prefer that we use your account to cover shipping charges)

UPS

FedEx

Clear

Shipping Account Number:

Quantity interested in: Ganaspis kimorum adults

Quantity interested in: Hadronotus pennsylvanicus adults

Additional comments

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Plant - PABIL Insects Purchase