NanoLight TechnologyTM - Fax Order Form

Please fill out this form for ordering products online. All orders are FOB and net 30days.

We also accept VISA/MC. Please contact us or fax us with your credit card information.

Tel: 928-367-1200 | Fax: 928-367-1205

Please include your:

Name:

Email:

Telephone:

Institution Name:

Billing Address:

Billing City, Sate, Country:

Billing Zip:

Shipping address:

Shipping City, Sate, Country:

Shipping Zip:

Fax Number:

Purchase order number:

Grant or Reference number:

Principal Investigator and/or contact person:

Type the letters in the white box:

*Shipping & handling on all U.S. orders, please add $30.00

International orders, please add $60.00 (U.S.)

All orders are FOB and Net 30 days!

** Required Fields

About | Order | Contact

NanoLights | NanoFuels | NanoFluors

P.O. Box 2746 | Pinetop, AZ 85935 | (Phone) 928-367-1200 | (Fax) 928-367-1205 | info@prolume.com