ORDER FORM (VIA MAIL OR FAX)

Name: _________________________________________________________________

Shipping Address: _______________________________________________________

City: _________________________ State: ___________________ Zip: _____________

Phone: _____________________________ Email: ______________________________

Product

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Quantity

_______

_______

_______

_______

Total

_______

_______

_______

_______

Check/Money Order ____

VISA ____   Mastercard ____   Discover ____

Shipping Total

GRAND TOTAL

_______

_______

_______

Card Number: ____________________________________

Expiration Date: ___________________________________

Signature: ________________________________________

Send order to: Applied Chemical Specialties, Inc., P.O. Box 241597, Omaha, NE  68124

Or fax to: (402) 390-9262

Shipping Costs:

$16 per 4-Pack/6-Pack (plus $4 per additional 4-Pack/6-Pack, regardless of product type)

$24 per case (plus $12 per additional case)

$1 per Test Packet

Express Shipment:  If you wish to have your order shipped by UPS Second Day Air, please contact us at: norosion@aol.com.  All orders shipped to Canada, Hawaii, Alaska, and Puerto Rico require shipping surcharges.

� Copyright 2020 Applied Chemical Specialties, Inc.