Make check payable to: To order please print this form and mail or Fax W/ payment.    Date:________________
D & D Chemical, Inc.
2065 Marion Ln.
Kinston, NC 28504
1(252)523-8255		 Fax: 1-252-523-8255
Mail to: Ship to: Phone:
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_____________________ _____________________ Email:
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(  )UPS                                      (  ) US Postal Service (  ) COD add $5.00 to total at bottom

Products will be shipped when out of state check have cleared our bank.
Description           Price                   Quantity         Total Cost
 TM-2000 Atomizing Humidifier           $ 175.00                   _______          ________
 .65  gph Nozzle & Filter           $ 11.95                   _______          ________
  1.0 gph Nozzle & Filter            $ 13.95                   _______          ________
 1.35 gph Nozzle & Filter           $ 15.95                   _______          ________
 Replacement Filter Kit 6-pack           $ 10.95                   _______          ________
TB-1 Rotating Drum Humidifier            $165.00                   _______          ________
    North Carolina Sales Tax 6%  
    Shipping & Handling             $12.75
    Total Cost          $ ________    

 

Name on Card: __________________________

Type of Card: (  ) Visa (  ) MasterCard (   ) American Express

Credit Card Number: _______________________     Exp Date: _______________