ChemSW, Inc. Order Form
Program Name QTY Part No. (P/N) Price Total
______________________________________ _____ _______________ _______________ _______________
______________________________________ _____ _______________ _______________ _______________
______________________________________ _____ _______________ _______________ _______________
______________________________________ _____ _______________ _______________ _______________
______________________________________ _____ _______________ _______________ _______________
______________________________________ _____ _______________ _______________ _______________
  Subtotal   _______________
California, New York, Wyoming, and Mississippi residents add appropriate sales tax   _______________
US Only: Shipping & handling 2% or $20 whichever is greater   _______________
  TOTAL   _______________
PAYMENT METHOD:
Note: All international orders must be pre-paid.
__ Check or money order payable to ChemSW, Inc.
__ Company purchase order #_________________________ (Must include authorized copy.)
__ VISA  __MASTERCARD  __AMEX  Expiration date: _______________
     Account #________________________________________________
     Signature (Required):_______________________________________
SHIP TO:
Name: _______________________________________
Company: _______________________________________
Department: _______________________________________
Address: _______________________________________
City: _______________________________________
State/Zip: _______________________________________
Phone: _______________________________________
BILL TO:
Name: _______________________________________
Company: _______________________________________
Department: _______________________________________
Address: _______________________________________
City: _______________________________________
State/Zip: _______________________________________
Phone: _______________________________________
HOW TO PLACE YOUR ORDER:
By Mail: ChemSW, Inc.
420-F Executive Court North
Fairfield, CA 94534
By Fax: 707-864-2815 24 hrs. per day 7 days a week
By Phone: 800-536-0404 or 707-864-0845
Mon-Fri 7am-4pm Pacific Time
By E-Mail: order@chemsw.com
WORK AREA:
__ Electronics
__ Food/Beverage
__ Forensics/Criminalistics
__ Environmental
__ Petrochemical/Petroleum
__ Pharmaceutical
__ Metal Finishing
__ Aerospace
 __ Biotech
__ Pulp/Paper
__ Power/Energy
__ Agriculture
__ Chemicals
__ Mining
__ Medical Lab
__ Other (specify)_________________

Job Title: ______________________________________________

NOTES:



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