EFS-2500 Order Form

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EFS-2500 Order Form

Instructions:
   1. Contact our sales associate to obtain product size, quantity, and pricing.
   2. Complete the order form and submit it. All information received will be kept confidential.
   3. Your Molecular-Tech sales associate will contact you to confirm the order.

Name/Company		PO Number
Address
City		Province/State
Postal Code/ZIP		Country
Telephone		Fax
Contact Person		Email
Tax#

Product	Size	Quantity	Price





	Freight
If Applicable, Custom Broker Charge
	Total Cost

Freight Method (Select One)
Prepaid Collect
If Collect, specify Courier	Account#

Payment Method (Select One)
Visa MasterCard EFT (Electronic Funds Transfer)
If Credit Card, specify Number	Exp. Date
If EFT, please contact Sales Rep.

Who is your contact person at Molecular-Tech Coatings ?

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