QWIK-RINSE, INC.

ORDER FORM

Print this form and send with check or money order to:
QWIK-RINSE, INC., P.O. Box 3453, Richmond, VA 23235
*** Discounts are available on orders of 3 or more - call or write to inquire ***
PRODUCT QUANTITY UNIT PRICE TOTAL
Commercial model rinser # $36.95 ea. $
Utility model rinser # $17.95 ea. $
Replacement probe tips -
For commercial rinser # $9.00 ea. $
For utility rinser # $9.00 ea. $
Subtotal $
Sales tax for Virginia purchasers, 4.5% $
Total amount of check or money order $
No charge for shipping and handling on single item orders

Ship to: ___________________________________________

Address: __________________________________________

City: ___________________________________ State: __________ Zip: _______________

Phone: _________________ Email: _____________________________________________