Kits Order Form
Please fill out the form clearly and return it by fax or email. Information provided will be used for kits production.
Company Name: Contact Person: Address: Delivery Address (name and/or address if different from above): Invoice Address (name and/or address if different from above):
Tel:
Fax:
E-mail:
Quotation No.: Sales Representative:
Client's PO No.: Order No.:
(For official use only)
Item 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Product Code
Description
Quantity
Unit Price
Sub Total
*With the payment to be settled by TT, an additional correspondent bank charge of USD$20.00 will be added to the total order amount.
Freight Charge Corresponding Bank Charge*
(For TT settlement only)
Total amount
Payment Method
Bank Transfer / ATM / Online Transfer By Cheque
Cheque No.: ___________________________________________ Drawn on (Bank): ______________________________________
By Credit Card Visa ¨ Master Card Holder Name: ________________________________________________ Card No.:
Expiry Date (mm/yy): _____________/________________ Card Validation Code**: __________________
□□□□ - □□□□ - □□□□ - □□□□
Card Holder Signature: ___________________________________
**Card Validation Code is the 3 or 4 digits security code is printed behind the Visa & MasterCard at the back of the signature panel.
Official use
Payment Received: Handled By:
PM03-020c (6/2010)
____________________________ ____________________________
Authorization Code: ___________________________ Date: ___________________________
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Terms and Conditions:
Buyer is advised to read the Terms and Conditions in the original quotation.

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