For Your Convenience:  Fill out this form online then Print and Fax it to (830) 964-4646 or Mail your Order & Payment to: AJP Chemical, 15377 FM 306, Canyon Lake, TX 78133.
 
*Name
 Company Name
*Mailing Address
*City  *State   *Zip
*Home Phone/Cell Phone #    Business Phone #    
*E-mail Address
Description
Size
(Click Button)
Price
(Each)
Quantity (Type Number)
Total Each (Input Amount)
 Secret Potion - Pina Colada
  Quart
$  9.95
  Gallon
$24.95
 Secret Potion - Orange Vanilla
  Quart
$  9.95
  Gallon
$24.95
 Secret Potion - Lemon
  Quart
$  9.95
  Gallon
$24.95
 Secret Potion - Bay Berry
  Quart
$  9.95
  Gallon
$24.95
 Secret Potion - Cherry
  Quart
$  9.95
  Gallon
$24.95
 PSP - Car Polish
  Quart
$10.95
 PSP - Furniture Polish
  Quart
$10.95
 Subtotal of above Order:
 
 Shipping Charges - Refer to Chart  (left)
 
 Sales Tax - Texas Residents Only - add 8.25%
 
 Total:
 
$0.01 - $25.00
$8.95
$25.01 - $49.00
$14.95
$49.01 - $75.00
$22.95
$75.01 - $100.00
$29.95
$100.01 +
add 30%
*Payment Options
Visa  MasterCard  American Express  Discover   * Check Money Order
Credit Card #    Expiration Date 
_____________________________________
Signature Line Credit Card Authorization                      (Form must be mailed for the Check or Money Order Box to be selected)
 
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