Indian Rocks Beach, FL 33785
(727) 642-0182
(813) 774-8657
(727) 593-3595 FAX
"Helping People Learn Compliance and Science" SM
Fax or E-mail "Cut & Paste" Form
| Product Description |
Quantity |
Cost |
| Total |
Shipping and Handling prices are for standard ground shipping only. Any special shipping requests (Overnight, International, etc.) should be noted and we will contact you with the complete information.
Ship To:
Name ______________________________________________________
Title _______________________________________________________
Company/Organization__________________________________________
Address_____________________________________________________
City, State, ZIP_______________________________________________
Business Phone_______________________________________________
E-Mail address_______________________________________________
FAX_______________________
Special shipping requests________________________________________
Desired Method of Payment
□ Check
□ Bill my company. (We must have a P.O. # to send an invoice.)
□ Wire Transfer (requires $15.00 processing fee)
□ Bill my credit card:
□ VISA □ MasterCard
Credit Card #________________________________________________
V-Code
(3 digit number on back of
card)_____________________
Expiration date _________/_________
Signature ___________________________________________________
Credit Card Billing Address:
Name______________________________________________________
Street Address_______________________________________________
City, State, Zip_______________________________________________
Please Fax or e-mail this form to:
Delphi Analytical Services, Inc.
Fax (727) 593-3595
info@delphianalytical.com
(Please note: All orders are non-refundable.)
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