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:

Name of person placing this order *

Bill to Same as Shipped to

Bill to Street

Bill to City

Bill to State

Bill to Zip Code

Thank you for your order. So that we may continue processing your order request, please fax or call our offices to provide your complete credit card information. Our fax number is +1-561-743-4088 or you can reach our customer satisfaction team directly by phone at +1-561-743-8090.

We require all of the following information to process your credit card order; if any information is not provided as requested, we will not be able to process your order:

Credit Card Type
Full Credit Card Number
Expiration Date
Name exactly as it appears on Credit Card
Credit Card Security Code (CVV Code)

Shipping Options:

Ship Via

Shipping Payment *

Account Number (Collect Shipments Only)

Ordering Information:

Qty.	Unit (gm, kg, etc.)	Sands Catalog #	Product Description	Unit Price (U.S. Dollars)	Total Price (U.S. Dollars)
1 - Qty	1 - Unit	1 - Catalog #	1 - Product Description	1 - Unit Price	1 - Total Price
2 - Qty	2 - Unit	2 - Catalog #	2 - Product Description	2 - Unit Price	2 - Total Price
3 - Qty	3 - Unit	3 - Catalog #	3 - Product Description	3 - Unit Price	3 - Total Price
4 - Qty	4 - Unit	4 - Catalog #	4 - Product Description	4 - Unit Price	4 - Total Price
5 - Qty	5 - Unit	5 - Catalog #	5 - Product Description	5 - Unit Price	5 - Total Price

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 *

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