Customer Order Form - Living Elements Ltd.  (please print and fax)

343 East 11th Street, North Vancouver, B.C. V7L 2H1
Phone: (604) 987 6992 / Fax: (604) 648 8182

Purchase Order #:____________________

Company Name / Contact Name:

 

 

Street:

City/Province State Postal Code/Zip 

 

 

 

Country

Phone

Fax

     
Shipping Address (If different from the above)

 

 

Preferred Airline Airline Account #: ___________________________  

FedEx Account#:________________________________________

Additional Notes: _________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

For Office Use Only:

PPReq. Y / N  Shipping only ___   100%___   Other ___________________

Invoice #________   PPD___   PPD___   Rec’d___

Organism

Quantity

Delivery Date  (approximate)