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PSG 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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