Ordering: Purchase Order Form

General Information Credit Application Purchase Order Form

Please do not use this form if you are ordering for the first time.
Call 800.336.9828 to place your order.

Company Information

Bold fields are required.

Company Name:
Customer Number: (if known)
Your Name:
Address 1:
Address 2:
City:
State:
Zip/Postal Code:
Country:
E-mail:
Phone:
Fax:

Product Information

Product Number	Quantity	Product Description

Shipping Information

Orders more than 12 cases will be shipped via truck. All other shipments will be via FedEx Ground unless otherwise indicated below:

Ship via Air ($38.00 CPI Hazmat Repacking Fee)

Overnight
2nd Day

COD ($10.00 FedEx Fee)
Saturday Delivery (not available to all locations)

Special Instructions:

Truck Line: Only for shipments over 12 cases

Payment Information Purchase Order Number:

Payment Method:
Open Account
COD
Visa
MasterCard
American Express

If paying by credit card, please complete the following:

Card Number:
Expiry Date: /
CVV Code:
Name on Card:
Card Address: Billing Address Same as Company Address

Chem-Pak, Inc.
Where Quality, Innovation, and Integrity Meet