LANCER FAX ORDER FORM
Please complete form, print and fax back to LANCER at (407)327-1229.
Qty
Item
Solution
Desciption
US
Total
LCD 2.5
P
S
H
2 x 2.5 gallons (5 gallons total = 1 box)
$99.00
 $
LCA 2.5
A
C
P
2 x 2.5 gallons (5 gallons total = 1 box)
$99.00
 $
LCD 5.0
P
S
H
1 x 5 gallons (5 gallons total = 1 box)
$99.00
 $
LCA 5.0
A
C
P
1 x 5 gallons (5 gallons total = 1 box)
$99.00
 $
LCD 30
P
S
H
30 gallon disposable drum
(20" Diam. x 30"H)
$435.00
 $
LCA 30
A
C
P
30 gallon disposable drum
(20" Diam. x 30"H)
$435.00
 $
LCD 55
P
S
H
55 gallon disposable drum
(23" Diam. x 35"H)
$750.00
 $
LCA 55
A
C
P
55 gallon disposable drum
(23" Diam. x 35"H)
$750.00
 $
LB LANCERBRITE Polish
(5 oz Aerosol Can)
$5.40
 $
SALT Water Softener Salt
$8.00
 $
Contact Name: Signature:
Phone: PO #: Original PO Required with Fax
Fax: Email:
Bill to: Ship to:
MC/VISA/AMEX: Exp: V-Code:*

LANCER USA, 3543 State Rd 419, Winter Springs, FL 32708, Phone: (407)327-8488
Email: chemsales@lancer.com

For Non-USA orders, please contact your LANCER Representative in Canada, Mexico, or Puerto Rico. Freight will be prepaid and added to your invoice. Please call LANCER at (800)332-1855 for shipping cost estimates. *Please provide V-Code for all credit card transactions (MC/Visa - last three numbers listed on signature panel.). Presenting a credit card which is declined will result in a service charge of $15.00 added to your order. Please ensure your card is up to date.