Order Form

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

Thank you!

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)
"Ship To" Company's Name (consignee that pays customs/duty taxes)
Ship To Company's Delivery 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.
Name of Billing Company/Organization
Billing Contact (person who receives the invoice)
First Last
Billing Contact's Email
Billing Contact's Telephone
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Payment Method (not actual payment at this time)*
- Credit Card
- Wire Transfer USD
- ACH Transfer
- Check USD
Message