To print order form, click your
mouse anywhere within the white area of the form and choose from the
option in your web browser, complete, then Fax
to 918-836-1308 or mail it with your
credit card info, check, or money order to Valhoma Corporation - 9925 E Admiral
Pl - Tulsa, OK
74116.
| Bill to name: | Daytime Phone: |
| Address: | Alternate Phone: |
| City: | Fax: |
| State: | Country: |
| Postal Zip: | Email: |
Payment by (circle one): Visa MC Check MoneyOrder COD |
|
| Credit Card # : | Expiration Date: |
| Signature of card holder: | |
| Ship to name (if different than above): | Daytime Phone: |
| Address: | Alternate Phone: |
| City: | Fax: |
| State: | |
| Postal Zip: | Email: |
| Item | Part # | Price | # of Items |
Shipping Charges (U.S. only-Shipping) |
||
| Gallon Each | 7212899 | $38.75
each $35.00 - 2 or more |
: |
Total amount of Purchase | Shipping Charge | Select One |
| Case Gallon (4) | 7112899 | $120.00
each $112.00 -2 or more |
: | $1.00-$20.00 |
$7.50 | |
| Pints | 7201699 | $6.95
each $6.00 - 2 or more |
: | $21.00-$50.00 | $12.00 | |
| Case Pints (12) | 7101699 | $55.00
each $50.00 - 2 or more |
: | $51.00 - $100.00 | $15.00 | |
| $101 and above | Actual charges will be applied | |||||
| Gel - 1lb. | 7201990 | $10.95
each $10.00 - 2 or more |
: | Calculate |
||
| Case (12) Gel - 1lb. | 7101990 | $106.00
each $96.00 - 2 or more |
: | Merchandise Total | $ | |
| Gel - 4oz. | 7200490 | $5.95
each $5.00 - 2 or more |
: | Shipping Total | $ | |
| Case (12) Gel -4oz. | 7100490 | $45.00
each $40.00 - 2 or more |
: | Tax (Oklahoma residents 8%) | $ | |
| Roll-on 3oz. | 7200390 | $5.95
each $5.00 - 2 or more |
: | Grand Total | $ | |
| Case (12) Roll-on 3oz. | 7100390 | $45.00 each $40.00 - 2 or more |
: | Signature (required): |
||