PCL Order Form

  
 

If previous customer please quote your Customer Code no. (as found on previous invoices)
 
 

Customer Order No.
 
 

Contact name:
 
 

Contact position:
 
 

Company name:
 
       
 

Invoice Information

    
 

Invoice Address:
 
 

 
 
 

 
 
 

Postcode/ Zip code:
 
 

Country:
 
 

Tel No. (include international dial code)
 
 

Fax No. (include international dial code)
 
 

E-mail:
 
 

Webpage address:
 
       
 

Delivery Information (Leave blank if same as Invoice Address )

 

  
 

Delivery Address:
 
 

 
 
 

 
 
 

Postcode/ Zip code:
 
 

Country:
 
 

Delivery Method: (Please note that shipping is extra)
 
 

 
 
 

Order Details

      
 

What type of product would you like to order?

Polymex product:
 
 

 

Rolls:

 
   

Sheets:
 
   

Other:
 
 

Product/ Polymex Codes: Enter as many products/ codes as you desire))
 
 

Quoted Price per Unit:
 
 

Material/ Product Description:
 
 

How would you like to pay for this order?
Account holder:
 
 

 
Credit Card:
 
   

Cheque:
 
 
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