Order Form

CUSTOMER NAME:
DATE:

P.O. Box 780034

San Antonio, TX 78278-0034

210-493-2999

210-493-3002 fax

BILLING ADDRESS
Addr 1:______
Addr2: ______
City: ______
State: ______Zip: ______
Telephone: ______
Fax: ______
SHIPPING ADDRESS
Addr 1:______
Addr2: ______
City: ______
State: ______Zip: ______
Telephone: ______
Fax: ______

Please check item and indicate quantity you wish to order, fill out the attached Credit Card Authorizationand return both forms by fax to 210-493-3002 or e-mail to .

TCD HAND SANITIZER
ITEM / DESCRIPTION / QUANTITY / PRICE EACH / TOTAL
1 oz.
(Box of 12) / Clear/citrus Antibacterial Hand Sanitizer. Sold in boxes of 12 - 1 oz. bottles. / Box
of 12: ______ / $17.50 ea. box
1 oz.
(Case of 12 boxes) / Clear/citrus Antibacterial Hand Sanitizer. Sold in case of 12 boxes (12 - 1 oz. bottles each box). / Case of
12 boxes: _____
(20% discount) / $168.00 ea. case
Active Ingredient Purpose
Ethyl Alcohol 62%...... Antiseptic
Use- For hand washing to decrease bacteria on the skin / Directions: Wet hands thoroughly with product and allow to dry without wiping.
Warnings
  • Flammable. Keep away from fire or flame.
  • When using this product, keep out of eyes. In case of contact with eyes, rinse with water.
  • Stop use and ask doctor if irritation and redness develops and persists.
  • Keep out of reach of children. If swallowed, get medical help or contact a Poison Control Center right away.
/ Other information: Store under 105⁰F.
Inactive ingredients Purified Water, Glycerin, Isopropyl Myristate, Carbomer, Aloe Vera, Fragrance
Drug Questions: 877-254-2281
Distributed by: 90807 Farmingdale, NY11735
SUBTOTAL
APPLICABLE SALES TAX AND SHIPPING WILL BE ADDED TO YOUR BILL
PLEASE FILL OUT THE ATTACHED CREDIT CARD AUTHORIZATION FORM AND FAX ALONG WITH THIS ORDER FORM TO 210-493-3002. THANK YOU / TOTAL

CREDIT/DEBIT CARD CHARGE

AUTHORIZATION AGREEMENT

(Complete form and fax to The Compliance Division, LLC (TCD) at 210-493-3002 or e-mail to )

I,______, the holder of (check one, please):

VISA _____ MasterCard _____ Amex _____ Discover _____

Card number: ______

Security Code ______Expiration date _____/_____

hereby authorize TCDto charge the amount

of (subtotal from Order Form)$ ______plus any applicable taxes

and/or freight charges for payment of products purchased on (date) ______.

I have read this entire agreement and understand that I will be held fully responsible for its terms and charges.

Cardholder: ______

Signature: ______

Company: ______

Billing Address: ______

City, State, Zip: ______

Telephone: ______

Date: ______

Your personal information will be protected from unauthorized access.

For questions regarding your order, call TCD at 210-493-2999