Make check payable to: To order please print this form and mail with  payment.    Date:________________
D & D Chemical, Inc.
2065 Marion Ln.
Kinston, NC 28504
1(252)523-8255
Mail Address: Ship to: Phone:
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_____________________ _____________________ Email:
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(  )UPS                                                        (  ) US Postal Service / Canada Name on Card:____________________________ 

Card Number: ________________________________        Exp: ________________     

Products will be shipped when out of state check have cleared our bank.
Description         Price                   Quantity         Total Cost
Clear Wave HD-1 *         $199.95                   _______          ________
ClearWave Standard Model *         $139.95                   _______          ________
18 Volt Replacement Transformer #  46300800         $26.95                   _______          ________
* Above unit come with a 18 V transformer   North Carolina Sales Tax 6%  
    Shipping & Handling             $12.75
    Total Cost          $ ________