Product Order and Payment Form
...Business Information
Company Name
Business Name
Authorising Person's Name
*
Physical Address 1
*
Physical Address 2
Postal Address 1
*
Postal Address 2
City
*
Postal Code
State / County / Province
*
Country
*
Website
Email Address
*
Phone
*
Fax
Mobile Phone
...Product Information
SE120 Quantity Ordered
5 litre @ RRP $69.90 + GST
FORMULA-1 Quantity Ordered
5 litre@ RRP $249.90 + GST
WP100 Quantity Ordered
20 litre @ RRP $249.90 + GST
SE120 Value
FORMULA-1 Value
WP100 Value
Total Value of order
*
Freight Cost
Any Further Information ?
...Payment Methods
Payment Method
(choose One)
*
Bank Transfer
Cheque
...by Bank Transfer
to The ANZ National Bank of New Zealand, Hamilton, New Zealand
account
Hi Image Enterprises Limited
# 06 0583 0460454 00
Please fill in details in payee particulars, code and reference - thank you.
...by Cheque
by CHEQUE written to
:
Effluent Treatment Solutions Limited, PO Box 27-419, Wellington
Copyright © 2005 Effluent Treatment Solutions Ltd
