Order Form                      Product        Quantity   Price   Item Total

Industrologic, Inc.             ____________   ________   _____   __________
3201 Highgate Lane
St. Charles, MO                 ____________   ________   _____   __________
63301  USA
                                ____________   ________   _____   __________
Phone: (800) 435-1975
       (636) 723-4000           ____________   ________   _____   __________
FAX:   (636) 724-2288
Email: info@industrologic.com   ____________   ________   _____   __________
Sales/Support: 9AM to 5PM Central
                                                  Product Total   __________

If shipping to a Missouri address add 5.90% for Sales Tax         __________

Shipments outside the US require your billable FedEx or UPS account number
unless you have made previous arrangements. Shipping charges, tariffs, and
any value added taxes (VAT) will be billed to this account number.

Normal domestic shipping is UPS with charges      1 Day Air __  2 Day Air __
added, or we can use your FedEx or UPS account    3 Day Select __  Ground __
number. We do not ship FedEx Ground.

FedEx account _____________________________ UPS account ____________________


Name: ________________________________________________ Date: ___ / ___ / ___

Company: ___________________________________________________________________

Address: ___________________________________________________________________

City: _________________________________ State: __________ Zip: _____________

Phone: __________________________ Email: ___________________________________


Credit Card: __ VISA  __ MasterCard   Expiration Date (MM/YY): __ __ / __ __

Name as it appears on card: ________________________________________________

Billing address of card: ___________________________________________________

Credit Card Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __

3 Digit Verification Number (from back of credit card): __ __ __

Purchase Order Number (if needed): ___________________