DIATOMITE USA

601 Winspear Road    Elma, NY 14059
Phone & Fax 716-651-9289 or 800-443-6693
 

PRINTABLE ORDER FORM
 
NAME:
(No P.O. Boxes)
ADDRESS1:
ADDRESS2:
CITY: STATE:
ZIP:
PHONE:
 

PRODUCT/SIZE

QUANTITY

DESCRIPTION

PRICE EACH

SHIPPING PRICE

TOTAL PRICE
(Example)   #3

1 Bag

40 L bags

$23.95

$16.00

$39.95
           
           
           
           
           
           
           
           
           
 

SUB TOTAL

  
 

NYS RESIDENTS ADD SALES TAX
 

GRAND TOTAL
 

CREDIT CARD INFORMATION

VISA

MASTER CARD

AMERICAN EXPRESS
CARD NUMBER:
EXPIRATION DATE:
 

BILLING INFORMATION (IF DIFFERENT FROM ABOVE)
NAME:
ADDRESS1:
ADDRESS2:
CITY: STATE:
ZIP:
PHONE:
 

Please make checks & money orders payable to: DIATOMITE USA

Please send payments to the address above.
 

To purchase our products in
Canada please see the "Canadian Contacts" listed on the web site.