Pure chemistry scientific Order Form

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Order Form for pure chemistry scientific Products
Bill To:
Ship To:
Name:
Attn:
Address:
Address:
Phone:
Fax:
Phone:
Fax:
Order Date
No.
Your Order #
Cat. No.
Order by
Product Description
Ship Via
Terms
FedEx
Net 30 days
Unit Price
Quantity
Total Price
Subtotal
Total
PO# or Credit Card Information (Visa, MC or American Express):
Name on card:
Mailing address:
Expiration Date:
Please fax or email this form at 1-617-206-9595 or [email protected] You may give your
credit card information over the phone at 8579282050.
Pure Chemistry Scientific Inc. 14905 SW freeway street #232, Sugarland, TX 77478, USA
Ph: 1-857-928-2050; Fax: 1-617-206-9595; Email: [email protected]
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