Custom Solution Request Form

Please fill out the form as completely as possible.

Company Name:
Contact Name:	Required
Fax:
Phone:
Address:
P.O. Box:
City:
State:
Zip Code:
Country:
E-mail Address:	Required
*Product Description:
	*Please include method (make-up and/or std. method if available). If a percent mix, indicate (w/v), (w/w) or (v/v), Also Molarity, Normality, grade of chemicals to be used.
Manufacturing Specs:	(+/- range)
Package Size:	(Quantity/Order)
Shelf Life (if known):	(Usage/Month)
Need Quote By:
Additional Info/ Comments:

QUALITY ASSURANCE
Reagents, Inc. is
an ISO 9001:2000 registered company. This certification assures our customers we are dedicated to the quality of our products and service.