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
Sales/Support: 9AM to 5PM Central
Email: info2008@industrologic.com                 Product Total   __________

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

Normal shipping is UPS with charges added, or     1 Day Air __  2 Day Air __
we can use your FedEx or UPS account number.      3 Day Select __  Ground __

FedEx account _____________________________ UPS account ____________________

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

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: _______________  Issued by: _________________________