Bill To:
Name __________________________________
Address __________________________________
City, State, Zip __________________________________
Daytime Phone __________________________________
Evening Phone __________________________________
E-Mail Address __________________________________

No-Rosion
FAX/ORDER FORM

Customer Service: NoRosion@aol.com
Fax 1-402-390-9262
email: norosion@aol.com
Payment:
Money Order
Certified Check
   
Please make checks or money orders payable to Applied Chemical Specialties. All forms of payment must be drawn on U.S. banks
 
Visa
Mastercard
       
Ship To:
Same as Bill To.
Name __________________________________
Address __________________________________
City, State, Zip __________________________________
Orders by online placement, fax, or e-mail can be paid for by credit card. Make sure that your card information is filled in correctly.

Orders by mail can be paid for by credit card, money order, certidied check, personal check, or business check.
Name as it appears
on the card 		_____________________________________
Card Number _________ _________ _________ ________
Expiration Date _________
  Signature ____________________________________
Your Order:
Quantity Description Size
Unit Price
Amount
         
         
         
         
         
SHIPPING CHARGE
We ship UPS ground unless otherwise specified. Use the chart to determine shipping, handling & insurance fee.
   
Subtotal
Shipping, Handling & Receiving
TOTAL
Product Type/Volume
Each Unit
Test Kit or Test Packet
$3.00
Pints
$6.00
Four-Packs
$7.00
Cases
$20.00
5 Gallon Pails
$30.00