Order Info (each KIT contains TEN tests)
Fields marked with ** are REQUIRED!
** NUMBER of KITS   X $102 USD =  
Add $5 for handling on single-kit order ... total $107.00
>>> 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    2nd Day 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

      Type special instructions below.    characters left

   

Gly-Tek Order Form