SECURE ONLINE ORDER FORM


If you have VISA or Mastercard, you can place an order with us by using the secure online order form below. Please make sure to fill out all the required information.

If you would like to order our products by using a company or university purchase order, or would like to request special payment terms (e.g. net 30 days), please send us your order by e-mail to info@adsdyes.com. If you have any questions, please don't hesitate to contact us.





BILLING INFORMATION
 
Full Name:*
Company/University/Institute:*
Address:*
Address (Line 2):
City:*
State / Province:
Country:*
Postal/Zip Code:
Phone Number: *
Fax Number:
E-mail: *
Special Instructions:*

 

SHIPPING INFORMATION
Full Name:*
Company/University/Institute:*
Address:*
Address (Line 2):
City:*
State / Province:
Country:*
Postal/Zip Code:
Phone Number: *
Fax Number:
E-mail: *
Special Instructions:*
Choose Shipping Method:*
Courier Account (if applicable):

 

YOUR ORDER
Catalog Number Quantity Price (USD)
Special Instructions:
Purchase Order Number:

 

PAYMENT INFORMATION
Name on Card:*
Card Type:*
Card Number:*         
Card Expiration:*   
Security Code (3-digits):*