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Customer Order Form

Customer Information

Click any/all that apply

Street Address

Address Line 2

Apt / Unit / Suite

Street Address

Address Line 2

Apt / Unit / Suite

Order Details

First / Last Name

(xxx) xxx-xxxx

Please provide card holder's direct phone number so we can make immediate contact with card holder to verify payment. This is required for us to begin processing your order. Credit cards cannot be accepted on this form or by email.

For existing customers who already have a line of credit with VersaFlex. Contact us if you don't know your Customer Name / Reference Number.

Product Details 1
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
There is an upcharge for this type/size packaging.
There is an upcharge for this type/size packaging.
There is an upcharge for this type/size packaging.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
Note: This color is NOT a Quick Ship color. Please allow additional processing time (48 - 72 hours) for this color / pigment selection. Also please be aware there will be an upcharge for this color / pigment selection.
Product Details 2
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
There is an upcharge for this type/size packaging.
There is an upcharge for this type/size packaging.
There is an upcharge for this type/size packaging.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
Note: This color is NOT a Quick Ship color. Please allow additional processing time (48 - 72 hours) for this color / pigment selection. Also please be aware there will be an upcharge for this color / pigment selection.
Product Details 3
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
There is an upcharge for this type/size packaging.
There is an upcharge for this type/size packaging.
There is an upcharge for this type/size packaging.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
Note: This color is NOT a Quick Ship color. Please allow additional processing time (48 - 72 hours) for this color / pigment selection. Also please be aware there will be an upcharge for this color / pigment selection.
Accessories

comes with: 2 tubes, 2 plungers, 2 d-caps, 1 nut, 3 ball bearings, 1 mixing wand

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A downloadable version is available as well, if needed. Please first download the form / save to your computer, then open with Adobe Acrobat Reader and complete.

Completed PDF forms can be emailed to customerservice@versaflex.com, or faxed to (913) 321-9007.