Geologic Resources: Order Form

Order Form Send or FAX order to: Geologic Resources 21 Pointe Rok Dr. Worcester, MA 01604 USA Email: dhb@geologicresources.com FAX: 508-329-3342 Phone: 508-425-7291 Toll Free: 877-234-3924 (USA)	Shipping Address: Name:_____________________________________________________________ Company:__________________________________________________________ Address:___________________________________________________________ City, State/Province: ________________________________________________ Postal Code:___________ Country:____________________________________ Email Address:______________________________________________________ Phone:____________________________________________________________ Type of Order: _____ Check/Money Order _____Credit
Product Description		Qty.	Price Each	Total Amount








Include shipping amount (From Product Sheet) ........................................................
State Tax (Massachusetts, USA orders only - 5%).......................................................
For Credit Card Orders (Visa and Mastercard accepted): Acct. No:______________________________________________________________________________ Type of card:_______________ Expiration date:_________________________ Security Code: ________ Account name:_________________________________________________________________________ Signature:____________________________________________________________________
Total Amount for this order ........................................................................
Name of Purchaser:
Terms are as follows: Shipments will not be made until payment has been received in US Dollars and has been accepted by our bank. Payment can be by credit/debit card, PayPal, check, or money order. Checks/money orders should be sent to Geologic Resources, c/o D. Bruehl, 21 Pointe Rok Drive, Worcester, MA 01604, USA. Payment must include the specified amount for shipping. We will make adjustments for correct shipping charges, if necessary. Massachusetts residents are subject to an additional 5% state sales tax. Checks or money orders should be made payable to "Geologic Resources". You may print this form which may be mailed or FAXed. Prices are subject to change without notice.