*Purchase Order No.	(You may use today's date)
*Organization	Type n/a for none.
*First Name
*Last Name
*Street Address
Address (cont.)
*City
*State/Province
*Zip/Postal Code
*Country
*Telephone
*E-mail	Your e-mail address will not be used for solicitation purposes.

Please provide the following ordering information:

	One Free Evaluation Sample to Authorized Government Personnel Only. Offer limited while quantities last. Place an X in the box to the left. May be a 2-oz. or 9-oz. Sample Skin Durx® Sample	Free
QTY	DESCRIPTION	PRICE
	1 Case. 12 Units 9-oz. Skin Durx®	$144.00
	1 Case. 6 Units 32-oz. Skin Durx®	$240.00
	1 Wall Dispenser 32-oz. Skin Durx® FOB	$  60.00

	SHIPPING METHOD: Please select only one.	PRICE
	UPS/FedEx Ground	$11.00 per case
	UPS/FedEx 2-Day Air	$18.00 per case
	UPS/FedEx Next Day Air	$22.00 per case

*Shipping prices will vary depending on quantity ordered. Total Order Cost:                  $        (includes shipping cost)

	SHIPPING ADDRESS
*Street Address
Address (cont.)
*City
*State/Province
*Zip/Postal Code
	PAYMENT OFFICER (If different from contact information.)
First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Telephone Number
Fax Number

          Comments:

IF YOU WANT A PRINTED COPY OF YOUR ORDER FOR YOUR RECORDS YOU MUST PRINT YOUR ORDER PRIOR TO CLICKING ON THE SUBMIT BUTTON.