Fill out this Order Form and mail with payment to: Hy-Tech ~ P.O. Box 216 ~ Melbourne, Fl 32902 ~ USA
Or FAX TO: 321-984-1022 Shipping prices shown are for 48 contiguous USA states only, All others call or email for quotes.

_______Gallons of metal Shield @ $49.95 per Gallon $
________5 Gallon Pails @ $249.75 Each $
Shipping Fee $22.00 per each One Gallon $
Shipping Fee $66.00 per each Five Gallon $
Hazmat Fee $30 per each Five Gallon $
Hazmat Fee $30 per up to 4 One Gallon (fee is per box. box holds up to 4 One Gallon cans) $
Fla. residents please add 7% sales tax. $
Total This Order $
Enter Special Instructions
Or Comments:
If paying with credit card (please check one)  ¤American Express | ¤ MasterCard | ¤ VISA | ¤PayPal

Credit Card Number or PayPal account email :________________________________________
Expiration Date:____________________________________________

Card Holder's Name:________________________________________
(as it appears on the card)
Street Address:______________________________________________________________________
(must be your credit card billing address)
City/State: ________________________________________________
Zip code: ____________
Phone:________________________________

Address to be shipped to (if different than above, no p.o. boxes):
Street Address: _________________________________________________________________
City/State: ________________________________________________
Zip code: ____________
Phone:________________________________

Your email address:______________________@_________________

CREDIT CARD AUTHORIZATION

Charge my credit card in the amount of:___________________
I understand that I am authorizing Hy-Tech to charge my credit card for the purchase(s) I have made above.

Signature:__________________________________________ Date:________________
Amount charged on your credit card will show up on your statement as Hy-Tech

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