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Customer Name: ____________________________________ Corporate Address: Street: ___________________________________ City: ______________________ State: ______ Zip: _________ Authorized Buyer: ____________________________________ Tel No: _____________________________________________ Cell No: ____________________________________________ E-Mail: _____________________________________________ Fax #: _____________________________________________ Web URL: ___________________________________________ Qty Unit Case(s) Description 45N 68W Natural Insect Repellent Price Total Fed Tax ID/Resale # ________________________________ Ship to Address: Check if same as Corporate Address Street: ____________________________________________ City: ______________________ State: ______ Zip: _______ * All Deliveries are made via USPS Priority Mail & most ship within 1-3 business days from our warehouse. Customer Internal Reference #: _________________________
PLEASE NOTE: Prices are subject to change at any time. This form MUST be completed in its entirety for your order to be processed. Please include a Method of Payment. Credit Card orders cannot be processed if any of the fields are left blank.
Sub Total S&H Grand Total A commercial case consists of 24 bottles Visa MasterCard American Express Wire Transfer Money Order Company Check Other (Make checks payable to 45N 68W Inc.) Cardholders Name: ___________________________________ Cardholders Address: __________________________________ Credit Card Number: ___________________________________ Day Telephone No: __________________________________ City: ______________________ State: ______ Zip: _______ Expiration Date: _________ Security Code: ______________
Cardholders Signature:_________________________________
45N 68W . P.O.Box 143, Jefferson Valley, NY 10535 e-Mail: orders@45N68W.com . Fax: 646-219-6091
Website: www.45N68W.com .Social Media twitter.com/45N68W . facebook.com/45N68W
45N 68W . P.O.Box 143, Jefferson Valley, NY 10535 e-Mail: orders@45N68W.com . Fax: 646-219-6091
Website: www.45N68W.com .Social Media twitter.com/45N68W . facebook.com/45N68W