This form is for U.S. Chemical order placement only. BILL TO: * Required Field *COMPANY NAME *ADDRESS *CITY *STATE *ZIP *COUNTRY SHIP TO: Same as Bill To *COMPANY NAME *ADDRESS *CITY *STATE *ZIP *COUNTRY *P.O. NUMBER *PERSON ORDERING *EMAIL ADDRESS *PHONE FAX		*ORDER DATE FREIGHT TERMS (A=Allow, B=Prepaid and Add, C=Collect) SHIP VIA CUSTOMER # SHIPPING WHSE SPLIT ORDER (Y/N)
*The PRODUCT DESCRIPTION, QTY and PKG SIZE fields must be filled in. UOM = Unit of Measure. PRODUCT CODE *QTY *PKG SIZE/UOM *PRODUCT DESCRIPTION PRICE/UOM WHSE STOCK

SHIP DATE	IN HOUSE DATE	ORDER NO.
SPECIAL INSTRUCTIONS		DATE ENTERED	TIME ENTERED	INITIALS	CREDIT APPR.