Nelco Gly-Tek - Order Form

How to Order the TestKit There are four ways to order your testkit(s): * E-mail (fill out this form, press Submit) - you can print a copy AFTER submitting; a copy will AUTOMATICALLY be sent to the e-mail address you provided * Fax (FIRST fill out this form, THEN print, fax to number above) * Regular Mail (FIRST fill out this form, THEN print 2 copies, mail ONE to address above) * Phone (call the number listed above)

The BEST way to send us an order is to fill out this form and press Submit. Do NOT e-mail credit card info ... connection is NOT secure! If using Mail or Fax, please fill out the form BEFORE printing it out ... your order will be much easier to read than if you print blank form and fill by handwriting!

*Order Info (each KIT contains TEN tests)*
Number of KITS	X $80 USD =
Add $5 for handling on single-kit order ... total $80.00 >>> prices do not include shipping <<<
P.O. Number:
*Buyer and Billing Information*
Buyer Name:
Company:
Division:
Billing Address:
City, St/Prov, Zip/Code:
Phone:	Fax:
E-mail:
Shipping Method:	Ground Air
*Fill below if DIFFERENT from billing address*
Attention:
Division:
Shipping Address:
City, St/Prov, Zip/Code:

If you would like a confirmation, how should we contact you?
E-mail Phone US Mail None needed

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