Mail and Fax Order Form | CLEAN-FLO

PRINT ORDER and MAIL or FAX to CLEAN-FLO INTERNATIONAL

Mail or Fax Order Form

Customer Address

Purchase Order Number

Name: ___________________________________
Address:___________________________________
City________________	State:_____	Zip ________________________

Vendor:	Ship To:
Clean-Flo International	Name:
540 East Union Street, Suite I	Address:
West Chester, PA 19382	City:	State:	Zip:
Phone 800-328-6656	Phone:

Quantity	Units	Description	Unit Price	Total
		Plus Shipping & Handling	5%

PAYMENT DETAILS	Sub Total
____ Check
	Shipping & Handling
____ Cash
____ Clean-Flo Account Number
	Taxes	State
____ Credit Card

Name: ___________________________________
CC#: ___________________________________
	Total
Expiration Date: _____ /_____ / _____
Shipping Date: _____ /_____ / _____