MAXR PRODUCT ORDER FORM

MAXR 100: Bonded Metallic Compound Cleanser PRICE: $50.00 per ounce

MAXR 200: Molecular Bonding Anti-Friction Lubricant PRICE: $3.00 per ounce

MAXR PRODUCTS MAY BE PURCHASED IN THE FOLLOWING QUANTITIES:

32 OUNCES: 1 QUART

128 OUNCES: 1 GALLON

7,040 OUNCES: 55-GALLON DRUM

PRODUCT: MAXR 100: QUANTITY

PRODUCT: MAXR 200: QUANTITY

SHIPPING & HANDLING $

TOTAL ORDER AMOUNT $

PURCHASER INFORMATION

COMPANY NAME:

CONTACT PERSON:

ADDRESS:

SUITE:

CITY, STATE, ZIP CODE:

COUNTRY:

@ $60.00 per ounce TOTAL $

@ $60.00 per ounce TOTAL $

PHONE:

FAX:

EMAIL:

PLEASE SEND YOUR ORDER VIA E-MAIL BY CLICKING THE "SEND" BUTTON.

THANK YOU FOR YOUR ORDER! PLEASE ALLOW 3 TO 5 BUSINESS DAYS FOR SHIPPING.