Customer Order Form

Your Name
Your Company Name

Address

City, State, Zip

Phone

E-Mail

How did you find us? What Search Engine?

Go To International Representative

Item                           Description                           Cost

Cardholder Name:   Card type:

Card Number:     Expiration date:

Online transaction are not secure

If cardholders address is different from the above
address please provide full address.

    Government  P.O.   Account

 

N.J. Residents Add 6% sales tax
Add shipping and handling

Feel free to fax or call in your order
Voice:732-469-5999   Fax 732-271-1824

Payment by check or money order - print form.
Mail completed form with payment to:

Med Pest Control & Supply
350 Mountain ave.
Middlesex N.J. 08846