Protech - Order Form

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Order Form

THIS IS A SECURE SITE. ALL INFORMATION SENT WILL BE ENCRYPTED, AND STORED ON A SECURE SERVER FOR YOUR PROTECTION.

*- Required fields.

Customer#:

Customer PO#:

*Phone #:

*E-Mail Address:

Dealer:

Dentist: Lab: Other:

Bill To:

*Name:

*Address:

*City:

State:

*Zip:

*Country:

Ship To (If different from billing address):

Name:

Address:

City:

State:

Zip:

Country:

Ship Via:

Item#	Qty	Description and Shade	US $ Amt.







		Merchandise Total:

All taxes, shipping, and hazardous charges (where applicable) will be added to invoices prior to shipping. Dealer discounts will be applied as earned. ORDERS UNDER $50 ARE SUBJECT TO A $10.00 HANDLING FEE.

Payment Information:

*Credit Card:

*Card Number:

*V-Code (3 digit code on back of MC, Visa ad Discover, and 4 digit code on front of AmEx):

*Name on Card:

*Expiration Date:

Year:

I have read and agree with the terms and conditions of sale Agree
If you have any questions relating to this form, e-mail us or call toll-free: 1-800-872-8898

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