Order Form
Calgonate Gel
Number of Tubes
Price per tube
Shipping fee
3-6
7-11
12-47
48 or more
$29
$29
$26
$26
$10
$14
$14
Free
Number of Kits
Price per Kit
Shipping fee
25g Tubes
3 tube minimum
1
2
3
4
5
6 or more
Emergency First Aid Kits
Including 2 x 25g tubes of
Calgonate Gel in each Kit
$149
$149
$149
$149
$149
$139
Company Name:
ACCT #
Telephone Number:
Fax Number:
E-mail Address:
Contact Person:
$17
$22
$28
$36
$42
Free
Shipping Address:
ATTN:
Address:
Suite:
City:
State:
Zip:
Country:
Shipping Location Telephone Number (If different from main #):
Billing Address:
Address:
Suite:
City:
State:
Zip:
Country:
Accounts Payable Telephone Number (If different from main #):
Please send
_ Calgonate Emergency Kits (incl. 2 x Calgonate 2.5% Gel Tubes in each).
Please send
_ tubes of Calgonate 2.5% Gel
If you are ordering both gel tubes and kits no minimum number of tubes applies, and the shipping fee for the kits will cover the entire cost of shipping.
Purchase Order Number
Total Cost (USD)$
How would you like your invoice sent to you? (Please choose one):
Credit card number:
Card type (MC, Visa, Amex.):
SIGNATURE
_ by Email
Exp date (MM/YY):
_ by Mail
/
_ by Fax
Security Code:
Name on Card:
_
DATE:
To place your order, please return this form to customerservice@calgonate.com or fax to 1-888-471-8615.
If you have any questions or requests, please call 1-888-434-3548 or visit our web site www.Calgonate.com.
Due to the nature of this product, no returns or credits will be authorized with the exception of damaged goods received.