 |
| Program Name |
QTY |
Program # |
Price |
Total |
| ______________________________________ |
_____ |
_______________ |
_______________ |
_______________ |
| ______________________________________ |
_____ |
_______________ |
_______________ |
_______________ |
| ______________________________________ |
_____ |
_______________ |
_______________ |
_______________ |
| ______________________________________ |
_____ |
_______________ |
_______________ |
_______________ |
| ______________________________________ |
_____ |
_______________ |
_______________ |
_______________ |
| ______________________________________ |
_____ |
_______________ |
_______________ |
_______________ |
| |
Subtotal |
_______________ |
| CA, MS, NJ, NY, WA and WY residents add appropriate sales tax |
_______________ |
| US Only: Shipping & handling $25 for 1-2 lb packages |
_______________ |
| |
TOTAL |
_______________ |
| PAYMENT METHOD: |
Note: All international orders must be pre-paid. |
| __ Check or money order payable to ChemSW, Inc. |
| __ Company purchase order #_________________________ |
| (Must include authorized copy.) |
| __ VISA __MASTERCARD __AMEX |
Expiration date: _____________________________ |
| |
Account #__________________________________ |
| |
Signature (Required):_________________________ |
|
|
| SHIP TO: |
| Name: |
_______________________________________ |
| Company: |
_______________________________________ |
| Department: |
_______________________________________ |
| Address: |
_______________________________________ |
| City: |
_______________________________________ |
| State/Zip: |
_______________________________________ |
| Country: |
_______________________________________ |
| Phone: |
_______________________________________ |
|
| BILL TO: |
| Name: |
_______________________________________ |
| Company: |
_______________________________________ |
| Department: |
_______________________________________ |
| Address: |
_______________________________________ |
| City: |
_______________________________________ |
| State/Zip: |
_______________________________________ |
| Country: |
_______________________________________ |
| Phone: |
_______________________________________ |
|
|
HOW TO PLACE YOUR ORDER
|
| By Mail: |
ChemSW, Inc.
4771 Mangels Blvd
Fairfield, CA 94585 |
| By Fax: |
707-864-2815 24 hrs. per day 7 days a week |
| By Phone: |
800-536-0404 or 707-864-0845 Mon-Fri 7am-4pm Pacific |
| By E-Mail: |
orders@chemsw.com |
|
|
|
WORK AREA:
|
__ Electronics
__ Food/Beverage
__ Forensics/Criminalistics
__ Environmental
__ Petrochemical/Petroleum
__ Pharmaceutical
__ Metal Finishing
__ Aerospace
|
__ Biotech
__ Pulp/Paper
__ Power/Energy
__ Agriculture
__ Chemicals
__ Mining
__ Medical Lab
__ Other (specify)_________________
|
|
Job Title: ______________________________________________
NOTES:
|