No-Rosion Order Form

Order Form

Instructions: Print a copy of the Order Form below. Complete all information, and send it to us via fax, or US Postal Service. Your order will be shipped within one day of our receipt of your completed Order Form. Orders are shipped via United Parcel Service (UPS) or Priority Mail, depending on your location, from our shipping location in Toledo, Ohio. If shipped via UPS, you will be notified via email of the tracking number at the time of shipment.

Express Shipment: If you wish to have your order shipped by UPS Second Day Air, please add double the shipping cost. All order shipped to Hawaii, Alaska, and Puerto Rico require double the shipping cost.

Shipping Costs:

$8 per Pint ($5 per Pint with order of 3 or more pints)

$12 per Four-Pack ($8 per Four-Pack with order of 3 or more Four-Packs)

Others: $24 per case, $40 per 5 gallon pail, $5 per Test Packet

ORDER FORM (VIA MAIL OR FAX)

Name: _________________________________________________________________

Shipping Address: _______________________________________________________

City: _________________________ State: ___________________ Zip: _____________

Phone: _____________________________ Email: ______________________________

Product

__________________________________________

Quantity

_______

Total

_______

Order Total

Shipping Total

GRAND TOTAL

_______

Payment Type:

Check/Money Order ____

VISA ____ Mastercard ____

Card Number: ____________________________________

Expiration Date: ___________________________________

Signature: ________________________________________

Send order to: Applied Chemical Specialties, Inc., P.O. Box 241597, Omaha, NE 68124

Or fax to: (402) 390-9262


	No-Rosion Coolant Corrosion Inhibitor	No-Rosion Cooling System Flush	HyperKühl SuperCoolant	HyperKühl SuperFlush	No-Rosion Coolant Test Packet	No-Rosion Lubrication System Passivator

DID YOU KNOW...

No-Rosion^® was in the cooling systems of seven award-winning classics at the 2008 Pebble Beach Concours d'Elegance!