ClorAm-X Order Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=200 BGCOLOR="#003333" TEXT="#F7F7FF" background="042d8c00dduajq.jpg"> <div> <A HREF="id38.htm" TARGET="_top" TITLE="ClorAmX"><U>ClorAm-X</U></A></div> <div> <B>ClorAm-X Order Form</B></div> <div> <A HREF="id49.htm" TARGET="_top" TITLE="System Design"><U>System Design</U></A></div> <div> <A HREF="id53.htm" TARGET="_top" TITLE="System Installation"><U>System Installation</U></A></div> <div> <A HREF="id24.htm" TARGET="_top" TITLE="AquaFuser"><U>Aqua-Fuser</U></A></div> <bR> </td> <td valign="top" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <FONT SIZE="5" COLOR="#0066FF" FACE="Arial" ><B>Live Seafood Systems</B></FONT><FONT SIZE="1" COLOR="#333399" FACE="Arial" >   </FONT>  |     <A HREF="index.htm" TARGET="_top" TITLE="Live Seafood Systems"><U>home</U></A></div> <div> back to  <A HREF="id47.htm" TARGET="_top" TITLE="Our Products and Services"><U><B>Our Products and Services</B></U></A></div> <div> ClorAm-X Order Form</div> <div>  <form action="http://csbmail.globalscape.com/cgi-bin/csbmail/csbmail.pl" method="POST" enctype="application/x-www-form-urlencoded"><input type="hidden" name="tlx_SortOrder" value="FirstName,LastName,Email,Company,Address1,Address2,City,State,Zip,Phone,Fax,MailingList"><input type="hidden" name="tlx_FormIndex" value="2"><input type="hidden" name="tlx_OKMessage" value="Thank you for your order."><input type="hidden" name="tlx_SendMode" value="1"><input type="hidden" name="tlx_Subject" value="A request form was submitted"><input type="hidden" name="tlx_EmailTo" value="rickg@ari1.com"> <table cellpadding="0" cellspacing="1" border="0" align="center"> <tr> <td align="left">First Name:<br> <input type="text" name="FirstName" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Last Name:<br> <input type="text" name="LastName" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Email:<br> <input type="text" name="Email" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Company:<br> <input type="text" name="Company" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Address Line 1:<br> <input type="text" name="Address1" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Address Line 2:<br> <input type="text" name="Address2" size="30" maxlength="100"></td> </tr> <tr> <td align="left">City:<br> <input type="text" name="City" size="30" maxlength="100"></td> </tr> <tr> <td align="left">State:<br> <input type="text" name="State" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Zip:<br> <input type="text" name="Zip" size="10" maxlength="10"></td> </tr> <tr> <td align="left">Phone Number:<br> <input type="text" name="Phone" size="14" maxlength="14"></td> </tr> <tr> <td align="left">Fax Number:<br> <input type="text" name="Fax" size="14" maxlength="14"></td> </tr> <tr> <td> <input type="checkbox" name="MailingList" value="yes"> Add me to your mailing list</td> </tr> <tr> <td align="right"><input type="reset"> <input type="submit" value="Send" name="tlx_send"></td> </tr> </table> </form>  </div> <bR> <div>  <A NAME="cloram_x_order_form"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>PRICING FOR CLOR-AM-X: </div> <div>  </div> <div> CLOR-AM-X, 5 LB. BOX                                $ 70.00 </div> <div>             </div> <div>  </div> <div> CLOR-AM-X, 10 LB BOX                               $125.00</div> <div>  </div> <div>  </div> <div> CLOR-AM-X, 55 LB.  BOX                             $280.00</div> <div>  </div> <div> Call 541-396-6886 for volume prices and further information.</div> <bR> <div> ALL PRICES ARE PLUS SHIPPING TO SITE.</div> <bR> <bR> </td> </tr></table></body>