Order Form - H.W. Sands Corp.

Ship To:

Company/Institution Name *

Address 1 *

Address 2

Mail stop/Suite

City *

State or Province *

Zip or Postal Code *

Area Code & Phone Number *

If outside of U.S. please
include country code

Email Address *

Area Code & Fax Number

Attention

*Bill To:

Credit Card Type *

Credit Card Number *

Expiration Date *

Name of person placing this order *

Name Exactly as it appears on Credit Card *

Bill to Same as Shipped to

Bill to Street

Please note:
Order Cannot be processed without this information

Bill to City

Bill to State

Bill to Zip Code

Credit Card Security Code *

Security Code

Shipping Options:

Ship Via

Shipping Payment *

Account Number (Collect Shipments Only)

Ordering Information:

Please be sure to check all information you have entered before sending.
You may also print this form and fax it to us.

I have read and agree to the Terms & Conditions * Yes

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