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To confirm your order please email or fax this fully
completed document, and a copy of both sides of your credit card to dgra@telus.net
or (604)931-4563, respectively.
You can print this form by selecting the browser Print option, or press
Ctrl+P.
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VectoBac 200G ORDER FORM
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I,_________________, authorize the charge of $_______________ CDN Dollars to my...(fill out only one)
VISA Number
_____________________________ (expiry date) _____ / _____
MC Number ______________________________
(expiry date) _____ / _____
AMEX Number ____________________________
(expiry date) _____ / _____
DISCOVERY Number
_______________________ (expiry date) _____ / _____.
This amount represents a payment in ful for ____ x 5 kg bags of VectoBac 200G @ $______ / bag = $______.
I authorize the full cost for this order, $ _______________, to be charged to the above credit card.
Prices (delivery and tax included)
* 1-3 bags @ $119.95 / 5 kg bag
* 4-7 bags @ $115.00 / 5 kg bag
* 8 or more bags @ $110.00 / 5 kg bag
By completing the above and signing below, I agree to be bound by both my Cardholder Agreement, and the above terms with respect to payment for this product.
Print name: ______________________________________ ( as shown on credit
card )
Home mailing address: ________________________________________________________________
Delivery address (if different from above)___________________________________________________
Credit card billing address:______________________________________________________________
Province/State ______ Postal code/zip ____________________
Telephone res: (____)_______________ bus: (____)_________________
cel: (____)_______________ fax: (____)_________________
Signature of cardholder X ____________________________Date: ______________________
You will be sent a confirmation of this transaction by regular or e-mail.
Thank you from D. G. Regan and Associates Ltd Environmental Services!
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