Nelco Gly-Tek - Order Form

How to Order the TestKit There are four ways to order your testkit(s): * E-mail Our online submittal option has recently been updated. Use the SUBMIT button at bottom; you will receive a confirmation e-mail if you have entered your own e-mail address. If any problems, please use one of the options below to order. * Fax FIRST fill out this form, THEN print, fax to number in left column) * Regular Mail FIRST fill out this form, THEN print 2 copies, mail ONE to address shown in left column; keep second copy for your records * PDF E-Mail Print filled-out form as PDF, send as attachment to e-mail in left column * Phone Call the number listed in left column

CONTACT INFO Billing 2234 Douglynn Lane St. Paul, MN 55119 Shipping 9741 Alvarado Lane N Maple Grove, MN 55311 Phone, Fax, E-Mail Phone: 651.738.2014 Fax: 651.738.9447 Email: nelcoLLC@comcast.net

*Order Info (each KIT contains TEN tests)* Fields marked with are REQUIRED!**
** NUMBER of KITS	X $XXXX USD =
Add $5 for handling on single-kit order ... total $XXXX >>> 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?
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EVALUATION COPY ONLY!

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Revised this page to prevent unauthorized access to EVAL form

20221292x rev retains 12/2 as changeover for price increase

NOTICE of PRICE INCREASE Kit Price will be $125 + shipping, effective January 1, 2023