ChromLab Fax Back Order Form

Please enter your order information on this form and fax this order to ChromLab at 610-644-2478 along with your credit card information. Thank you.

Billing Address:

 
First Name:
Last Name:
Company:
Mailing Address:
City: State:
Zip Code:
Phone Number:
Fax Number:
E-mail Address:
Shipping Address: Fill out only if you wish your order shipped to a different address than the one specified under billing.
First Name:
Last Name:
Company:
Mailing Address:
City: State:
Zip Code:
Phone Number:
Fax Number:
Part Number: Description: Quantity: Price Each: Extended Price:
  Subtotal
Pennsylvania Residents add 6.00% sales tax or attach PA Tax Exemption Certificate. Tax
Shipping and handling will be added to all orders. Total Price
Method of Payment:
Charge to my Credit Card Check or Money Order
Credit Card Type: Visa, MasterCard, American Express
Credit Card Number: Expiration Date: Month/Year
Card Holder Name:
Signature:

Important Notice: Changes of cost require that ALL PRICES ARE SUBJECT TO CHANGE WITHOUT NOTICE.