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
 		 You may Fax your order to:   1-252-523-8255
Mail to: Ship to: Phone:
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_____________________ _____________________ Email:
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(  )UPS                                      (  ) US Postal Service Name on Card:____________________________ 

Card Number: ________________________________        Exp: ________________     

* Products will be shipped when out of state check have cleared our bank.
Description                   Price                   Quantity         Total Cost
Condensate Pump only    20 +UL  $55.00                   _______          ________
Condensate Pump with Switch 20 +ULS  $60.00                   _______          ________
220V Pump with Switch  20+ULS-220V  $62.50                   _______          ________
Secondary Safety Switch   CFS-1  $8.50                   _______          ________
                      _______          ________
    North Carolina Sales Tax 6%  
    Shipping & Handling             $12.75
                          Total Cost        $ ________