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

Customer Order Form

Customer Information

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.

Click any/all that apply

Name & Phone of person to notify of delivery
Name & Phone number of person to set delivery appointment details
Number for Ship To location

Street Address

Address Line 2

Apt / Unit / Suite

Street Address

Address Line 2

Apt / Unit / Suite

Order Details

First / Last Name

(xxx) xxx-xxxx

Contact Email Address
Please select payment method
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

Use PO# / name for your records
Name of job where product will be used

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.
This item has DOT HAZMAT restrictions.
Please note: Roughguard is only available in VF 1280 Black.
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.
Number of containers / packages needed
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 Details 2

This product has DOT HAZMAT restrictions.
This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
Please note: Roughguard is only available in VF 1280 Black.
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.
Number of containers / packages needed
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 Details 3

This item is made-to-order. Please be aware that this could increase production lead time, and may influence shipping dates / availability.
This product has DOT HAZMAT restrictions.
Please note: Roughguard is only available in VF 1280 Black.
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.
Number of containers / packages needed
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.
Note: If you have additional products to order, please enter them in the Special Instructions below.

Accessories

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.

Order / delivery requirements

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.