ORDER FORM (VIA MAIL OR FAX)

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Shipping Address: _______________________________________________________

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Phone: _____________________________ Email: ______________________________

Product

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Quantity

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

Or fax to: (402) 390-9262

Shipping Costs:

$8 per Pint ($5 per Pint with order of 3 or more)

$12 per Four-Pack ($8 per Four-Pack with order of 3 or more)

Others: $24 per case, $40 per 5 gallon pail, $5 per Test Packet

Express Shipment:  If you wish to have your order shipped by UPS Second Day Air, please add double the shipping cost. All order shipped to Hawaii, Alaska, and Puerto Rico require double the shipping cost as well.

© Copyright 2008 Applied Chemical Specialties, Inc.