Order
Form - Please print and complete
Name:_______________________________________________
Company:____________________________________________
Repeat Customer: YES / NO - If YES Customer PO Numer:_________________
| Product | Price / Quantity Per Box | Quantity Ordered | Total Cost |
| EASICULT TTC | 10 tests per box - $45.00 | ||
| EASICULT COMBI | 10 tests per box - $53.00 | ||
| EASICULT - S | 9 tests per box - $46.00 | ||
| Liqui-Cult Aviation Test Kit | 10 tests per box - $90.00 | ||
| MCE COMBI Microbial Test Kits | 10 tests per box - $30.00 |
Billing Information
Address One:__________________________________________
Address Two:__________________________________________
City:____________________________ State:_______________ Zip:________________
Phone: ____________________ Fax: ______________________
E-Mail:________________________________________________Ok to e-mail invoices? Yes/No
Shipping Information (Same as Billing __ )
Name:_______________________________________________
Company:____________________________________________
Address One:__________________________________________
Address Two:__________________________________________
City:_____________________________ State:_______________ Zip:_______________
Product Selection
Payment Method: ___Check/Money Order ___ Visa ___ MasterCard ___American Express
Credit Card #:_____________________________ Exp. Date ________________
Name on Card:____________________________
Comments:_________________________________________________________________
___________________________________________________________________________
Contact Information
MCE Chemicals & Equipment Co., Inc
Technical Products Division
2442 Main Street, PO Box 990
Lake Placid, NY 12946
(518) 523-2355 Fax (518) 523-2821 Email:
mce@capital.net __________________________________________________________________________