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Instructions
Print this form, then fill in your address and payment information in the space
provided and fax or mail it to us at:
BOREAL LABORATORIES Order Toll-Free
399 VANSICKLE ROAD Phone: 800-387-9393 Fax: 800-668-9106
ST. CATHARINES, ON L2S 3T4
http://www.BOREAL.com
PURCHASE ORDER FORM FOR DATE: 5/12/2008
www.BOREAL.com
BILL TO:
____________________________________
SHIP TO:
____________________________________
Name Name
____________________________________ ____________________________________
Company Company
____________________________________ ____________________________________
Street Address Street Address (Do not use a PO Box)
____________________________________ ____________________________________
Street Address (line 2) Street Address (line 2)
____________________________________ ____________________________________
Street Address (line 3) Street Address (line 3)
____________________________________ ____________________________________
City State ZIP City State ZIP
____________________________________ ____________________________________
Country Country
____________________________________ ____________________________________
Phone Ext. Phone Ext.
____________________________________ ____________________________________
Fax Fax
____________________________________ ____________________________________
E-mail E-mail
PAYMENT:
_____ Check Enclosed: $_________________ (Make Payable to Boreal)
_____ Credit Card: ___VISA ___MasterCard
Credit Card Number: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Card Security Code: ________________
Expiration Date: ____/____
Name on Card: ________________________________________________________
Signature: ___________________________________________________________
Shipping Method (if other than Standard): ___Next Day
Please tell us why you chose the print/fax option instead of completing this order
online with a credit card:
__________________________________________________________________________________
__________________________________________________________________________________
THANK YOU FOR ORDERING VIA www.BOREAL.com!
ORDER BY MAIL, FAX, PHONE,
OR ON THE INTERNET
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