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100% Pure Polyurea Protective Coatings and Lining Systems

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Customer Order Form

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Customer Order Form

Have an existing Purchase Order created by your own system? Click here to use our file upload form instead.

Customer Order Form

Customer Information

New Customer(required)

Yes

Have you spoken with a VersaFlex Sales Rep?(required)

Yes

Name of VF Rep(required)

Company Name(required)

Customer / Ordered By(required)

Customer Phone Number(required)

Delivery or Customer Pick-up(required)

Delivery

Customer Pick-up

For Customer Pickup: Shipping charges will apply if product is not picked up within 48 hours. No additional product may be added at time of pickup.

Is this a Job Site?(required)

Yes

Business or Residential(required)

Business

Residential

Shipping Location Requirements

Truck Lift Gate Needed

Pallet jack (on truck) Needed

Call Notify

Appointment Required

Existing Off-loading Dock at site

Click any/all that apply

Call Notify(required)

Name & Phone of person to notify of delivery

Appointment Required(required)

Name & Phone number of person to set delivery appointment details

Special Delivery Instructions

Name(required)

Shipping Phone Number(required)

Number for Ship To location

Shipping Address(required)

Street Address

Address Line 2

Apt / Unit / Suite

City / Town(required)

State / Province(required)

Customs Broker Name(required)

Customs Broker Phone Number(required)

Zip / Postal Code(required)

Billing Address different than Shipping Address?(required)

Yes

Billing Address(required)

Street Address

Address Line 2

Apt / Unit / Suite

Billing City / Town(required)

Billing State / Province(required)

Zip / Postal Code(required)

Order Details

Date Required

Order Contact Name

First / Last Name

Order Contact Phone

(xxx) xxx-xxxx

Order Confirmation Email address(required)

Contact Email Address

Do you have a billing account set up with us?(required)

Please select payment method

Yes

Card Holder's Phone Number(required)

We will contact the card holder as soon as possible. This is required to begin processing your order.

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.
DO NOT TRANSMIT CREDIT CARD INFORMATION

Purchase Order Reference(required)

Use PO# / name for your records

Project / Job Name

Name of job where product will be used

Product Details 1

Product / Item 1(required)

This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.

This item has DOT HAZMAT restrictions.

Packaging / Size(required)

600 mL cartridges / case of 10

Packaging / Size(required)

2 gal kit (1A & 1B)

10 gal kit (5A & 5B)

Packaging / Size(required)

2 gal kit (1A & 1B)

Packaging / Size(required)

110 gal kit (55A & 55B)

10 gal kit (5A & 5B)

Packaging / Size(required)

106 gal kit (53A & 53B)

10 gal kit (5A & 5B)

Packaging / Size(required)

10 gal kit (5A & 5B)

600 mL cartridges / case of 10

Packaging / Size(required)

55 gallon drum

5 gallons

1 gallon

Packaging / Size(required)

3 gal kit (1A & 2B)

Packaging / Size(required)

2 and 1/2 gallon kit (pre-measured bags of A & B in a 5 gal pail)

Packaging / Size(required)

110 gal kit (55A & 55B)

60 gal kit (30A & 30B)

10 gal kit (5A & 5B)

There is an upcharge for this type/size packaging.

Packaging / Size(required)

10 gal kit (5A & 5B)

2 gal (1A & 1B)

600 mL cartridges / case of 10

Packaging / Size(required)

1 gal, 1 container of catalyst

Packaging / Size(required)

110 gal kit (55A & 55B)

10 gal kit (5A & 5B)

600 mL cartridges / case of 10

Packaging / Size(required)

10 gal kit (5A & 5B)

2 gal kit (1A & 1B)

Packaging / Size(required)

10 gal kit (5A & 5B)

2 gal kit (1A & 1B)

600 mL cartridges / case of 10

Packaging / Size(required)

4 gal kit (1A & 3B pigmented)

3 gal kits (1A & 2B-clear)

1 gal kit (1A & 3B-pigmented)

.75 gallon kit (1A & 2B-clear)(1A & 3B-pigmented)

Packaging / Size(required)

10 gallon kit

600 mL cartridges / case of 10

Packaging / Size(required)

106 gal kit (53A & 53B)

60 gal kit (30A & 30B)

30 gal kit (15A & 15B)

10 gal kit (5A & 5B)

There is an upcharge for this type/size packaging.

Packaging / Size(required)

110 gal kit (55A & 55B)

30 gal kit (15A & 15B)

10 gal kit (5A & 5B)

Packaging / Size(required)

1.5 gal kit

Packaging / Size(required)

3 gal kit (1A & 2B-clear)

This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.

Number of Packages(required)

Number of containers / packages needed

Product 1 Color (FlexTain)

VF1223 Tan

1000 Series Color(required)

VF Color Requested?

Note: This color is NOT a Quick Ship color. Please allow additional processing time (2 - 3 business days) for this color / pigment selection. View Quick Ship & Alternate color charts here.

Product 1 Color, 1000 Series(required)

Product 1 Color, 2000 Series(required)

Product 1 Color, 5000 Series(required)

Product 1 Color, 7000 Series(required)

Do you need to add another product to this order?

Add another product

Product Details 2

Product / Item 2(required)

This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.

This item has DOT HAZMAT restrictions.

Packaging / Size(required)

2 gal kit (1A & 1B)

10 gal kit (5A & 5B)

Packaging / Size(required)

2 gal kit (1A & 1B)

Packaging / Size(required)

110 gal kit (55A & 55B)

10 gal kit (5A & 5B)

Packaging / Size(required)

106 gal kit (53A & 53B)

10 gal kit (5A & 5B)

Packaging / Size(required)

10 gal kit (5A & 5B)

600 mL cartridges / case of 10

Packaging / Size(required)

55 gallon drum

5 gallons

1 gallon

Packaging / Size(required)

3 gal kit (1A & 2B)

Packaging / Size(required)

2 and 1/2 gallon kit (pre-measured bags of A & B in a 5 gal pail)

Packaging / Size(required)

110 gal kit (55A & 55B)

60 gal kit (30A & 30B)

10 gal kit (5A & 5B)

There is an upcharge for this type/size packaging.

Packaging / Size(required)

10 gal kit (5A & 5B)

2 gal (1A & 1B)

600 mL cartridges / case of 10

Packaging / Size(required)

1 gal, 1 container of catalyst

Packaging / Size(required)

110 gal kit (55A & 55B)

10 gal kit (5A & 5B)

600 mL cartridges / case of 10

Packaging / Size(required)

10 gal kit (5A & 5B)

2 gal kit (1A & 1B)

Packaging / Size(required)

4 gal kit (1A & 3B pigmented)

3 gal kits (1A & 2B-clear)

1 gal kit (1A & 3B-pigmented)

.75 gallon kit (1A & 2B-clear)(1A & 3B-pigmented)

Packaging / Size(required)

10 gallon kit

600 mL cartridges / case of 10

Packaging / Size(required)

106 gal kit (53A & 53B)

60 gal kit (30A & 30B)

30 gal kit (15A & 15B)

10 gal kit (5A & 5B)

There is an upcharge for this type/size packaging.

Packaging / Size(required)

110 gal kit (55A & 55B)

30 gal kit (15A & 15B)

10 gal kit (5A & 5B)

Packaging / Size(required)

3 gal kit (1A & 2B-clear)

This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.

Number of Packages(required)

Number of containers / packages needed

Product 2 Color (FlexTain)

VF1223 Tan

1000 Series Color(required)

VF Color Requested?

Note: This color is NOT a Quick Ship color. Please allow additional processing time (2 - 3 business days) for this color / pigment selection. View Quick Ship & Alternate color charts here.

Product 2 Color, 1000 Series(required)

Product 2 Color, 2000 Series(required)

Product 2 Color, 5000 Series(required)

Product 2 Color, 7000 Series(required)

Do you need to add another product to this order?

Add another product

Product Details 3

Product / Item 3(required)

This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.

This item has DOT HAZMAT restrictions.

Packaging / Size(required)

600 mL cartridges / case of 10

Packaging / Size(required)

2 gal kit (1A & 1B)

10 gal kit (5A & 5B)

Packaging / Size(required)

2 gal kit (1A & 1B)

Packaging / Size(required)

110 gal kit (55A & 55B)

10 gal kit (5A & 5B)

Packaging / Size(required)

106 gal kit (53A & 53B)

10 gal kit (5A & 5B)

Packaging / Size(required)

10 gal kit (5A & 5B)

600 mL cartridges / case of 10

Packaging / Size(required)

55 gallon drum

5 gallons

1 gallon

Packaging / Size(required)

3 gal kit (1A & 2B)

Packaging / Size(required)

2 and 1/2 gallon kit (pre-measured bags of A & B in a 5 gal pail)

Packaging / Size(required)

110 gal kit (55A & 55B)

60 gal kit (30A & 30B)

10 gal kit (5A & 5B)

There is an upcharge for this type/size packaging.

Packaging / Size(required)

10 gal kit (5A & 5B)

2 gal (1A & 1B)

600 mL cartridges / case of 10

Packaging / Size(required)

1 gal, 1 container of catalyst

Packaging / Size(required)

110 gal kit (55A & 55B)

10 gal kit (5A & 5B)

600 mL cartridges / case of 10

Packaging / Size(required)

10 gal kit (5A & 5B)

2 gal kit (1A & 1B)

Packaging / Size(required)

4 gal kit (1A & 3B pigmented)

3 gal kits (1A & 2B-clear)

1 gal kit (1A & 3B-pigmented)

.75 gallon kit (1A & 2B-clear)(1A & 3B-pigmented)

Packaging / Size(required)

10 gallon kit

600 mL cartridges / case of 10

Packaging / Size(required)

106 gal kit (53A & 53B)

60 gal kit (30A & 30B)

30 gal kit (15A & 15B)

10 gal kit (5A & 5B)

There is an upcharge for this type/size packaging.

Packaging / Size(required)

110 gal kit (55A & 55B)

30 gal kit (15A & 15B)

10 gal kit (5A & 5B)

Packaging / Size(required)

3 gal kit (1A & 2B-clear)

This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.

Number of Packages(required)

Number of containers / packages needed

Product 3 Color (FlexTain)

VF1223 Tan

1000 Series Color(required)

VF Color Requested?

Note: This color is NOT a Quick Ship color. Please allow additional processing time (2 - 3 business days) for this color / pigment selection. View Quick Ship & Alternate color charts here.

Product 3 Color, 1000 Series(required)

Product 3 Color, 2000 Series(required)

Product 3 Color, 5000 Series(required)

Product 3 Color, 7000 Series(required)

Accessories

Accessories needed?

Yes

Cartridge Set (empty)

600 ML

comes with: 2 tubes, 2 plungers, 2 d-caps, 1 nut, 3 ball bearings, 1 mixing wand.
If for low pressure spray material, please note that in the special instructions below.

# of Cartridge Sets

1/2" Mixing Wands

1/2 inch Static Mixing Wand - 30 element - PL00030

# of 1/2" Mixing Wands

1/2" AST Aluminum Nuts

1/2 inch Aluminum nuts (re-usable) - ME00002

# of Aluminum nuts

1/2" AST Plastic Nuts

1/2 inch Plastic nuts (single use) - PL00018

# of Plastic nuts

Spray Manifold

Spray Manifold - PL00012

# of Spray Manifolds

Spray Wand

Spray Wand - PL00011

# of Spray Wands

Caulk Guns

Manual Caulk Gun 300x300mL - CG00004

Pneumatic Caulk Gun 300x300mL - CG00003

18V Battery Powered Caulk Gun 300x300mL - CG00001

Extra Battery Only – CG00002

# of Manual Caulk Guns

# of Pneumatic Caulk Guns

# of Battery Powered Caulk Guns

# of Extra Batteries

Low Pressure Spray Setup for use with CG00003

Setup for Low Pressure Spray - CG00005

Special Instructions

Order / delivery requirements

Terms:(required)

By submitting this order, I agree that no further changes can be made, and I authorize VersaFlex to process this order as submitted.

This field should be left blank

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.

Download fillable/savable PDF version here.

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