Order Form

If you already have a quote or Aquagenx pricing, send in the form below. Orders are confirmed via email.

After the shipment is created, we will email you the invoice and information on how to make payment. Payment is due prior to shipping.

Today's Date
MM slash DD slash YYYY
Quote Number
Delivery Deadline
MM slash DD slash YYYY
Your Name*
First Last
Your Email*
Your Phone*
Product Number x Quantity (Example: CBT-ECTC-MPN-100 x 5)*
Preferred Shipping Method from Quote (Example: FedEx Priority)
Shipping Company Name (company/organization to whom we're shipping and is the consignee that pays customs/duty taxes)
Shipping Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is this a residential address?*
- Yes
- No
Shipping Contact's Name
First Last
Shipping Contact's Email
Shipping Contact's Telephone
Billing Contact Info
- Select if same as shipping info. If different, fill in fields below.
Billing Name
First Last
Billing Company/Organization
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Billing Email
Billing Telephone
Payment Method (not actual payment at this time)*
- Credit Card
- Wire Transfer USD
- ACH Transfer
- Check USD
Message