MAIL ORDER FORM

For orders by mail and fax.

PRODUCTS	QUANTITY	PRICE	SHIPPING
Sub-Totals
Connecticut residents please add a 6% sales tax of the Price Sub-Total
Please add Sub-Totals Product Price + Shipping + Sales Tax = Grand Total			$
Special Instructions:

SHIPPING ADDRESS
First Name      Last Name  Street Address  City      State/Province  Zip/Postal Code      Country  Daytime Phone      Email Address

PAYMENT INFORMATION
Payment Method    by money order (enclosed)      by check (allow several days to clear)      Visa       MasterCard       American Express Card Number  Expiration  Authorized Signature      Order Date

BILLING ADDRESS  (only for credit card orders)
If different from Shipping Name or Address: First Name      Last Name  Company  Street Address  City      State/Province  Zip/Postal Code      Country

FORWARDING ADDRESS FOR ORDERS
Novion RadonSeal    18 L'Hermitage Drive Phone: (203) 225-0366 or 1-800-472-0603    Shelton, CT 06484 USA Fax:    (203) 225-0367

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Any questions? Please contact us by e-mail or phone toll-free 1-800-472-0603 or 203-225-0367

MADE IN USA
Products not sold through retail stores. Available exclusively from:
Radon Mitigation & Concrete Waterproofing Co., Novion Inc.,
18 L'Hermitage Drive, Shelton, CT 06484 USA
RadonSeal™ is a registered trademark. Copyright © 1998-2010. All rights reserved.