Dimachem Inc. 3258 Marentette Ave, Windsor, ON, N8X 4G4 519-969-5570

Sales Order / Proof of Delivery (POD) Form

Section 1: Basic Information

Customer:

Address:

Section 2: Order Details

Product Description

Part #

Jug(s)

Pails(s)

Drum(s)

Sell Price ($)

Section 3: Confirmation

Date:

Sales Representative:

PO or Requisition number?

                    X_________________________________________________________

                                        Customer Authorization Signature

(Signature Confirms order, price and/or  receipt of materials and authorizes payment for goods received.)

Name (printed)