ChemSW, Inc. Order Form
Program Name QTY Program # Price Total
______________________________________ _____ _______________ _______________ _______________
______________________________________ _____ _______________ _______________ _______________
______________________________________ _____ _______________ _______________ _______________
______________________________________ _____ _______________ _______________ _______________
______________________________________ _____ _______________ _______________ _______________
______________________________________ _____ _______________ _______________ _______________
  Subtotal   _______________
California, Missippi, New York and Wyoming 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: order@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: