Clearwater GMX Mail Order Form

GMX Product Mail Order Form ---- Ordering Instructions:

Print this page and Fill out this Form by Hand.................... OR ............
Fill out this Form then Print this page twice (keep one copy for your records).
Mail this Form with your Payment to the address in the Upper Left Corner.

GMX Product Mail Order Information
Item / Description	Qty		Price		Amount
Diamond Home System - Model 4800		x	$ 716 sys.	=	$
Platinum Home System - Model 3800		x	$ 537 sys.	=	$
7 Star Pool System - Model 4848		x	$ 716 sys.		$
6 Star Pool / Spa System - Model 2848		x	$ 358 sys.	=	$
5 Star Spa System - Model 1848		x	$ 179 sys.	=	$
Order Individual Devices for Commercial and Industrial Applications Below.
GMX Model 400 Device (for 1/8" to 1/2" Pipes)		x	$ 125 ea.	=	$
GMX Model 800 Device (for 1/2" to 1-1/4" Pipes)		x	$ 179 ea.	=	$
GMX Model 848 Device (for 1-1/4" to 3" Pipes)		x	$ 179 ea.	=	$
GMX Model 8000 Device (for 3" to 8" Pipes)		x	$ 480 ea.	=	$
Order Sub Total				:	$
Arizona Resident, Please Add 5.75% State Sales Tax ..............				:	$
Shipping & Handling, $4 per device ($20 Max)				:	$
Order Grand TOTAL (U.S. Dollars)				:	$

Shipping Information --- * Denotes Required Field.

* First Name:

* Last Name:

Company Name (optional):

E-Mail Address (optional):

* Shipping Address:

* City:

* State / Province:

* Zip:

* Country, if outside the Continental U.S., additional shipping charges may apply:

* Phone Number:

If outside the USA / Canada,
Country Code:

Credit / Debit Card Payment Information ( not needed w/check ) --- * Denotes Required Field.

* Select Type Of Credit / Debit Card		* Credit / Debit Card Number:	* Expiration Date:
	Visa	* Exact Name On Card:
	MC	* Your credit / debit card billing address is REQUIRED BELOW ONLY if it is different from the shipping address listed above.**

Billing Address:

City:

State / Province:

Zip Code:

Country:

Phone Number:

If outside the USA / Canada -
Country Code:

Delivery can be expected within a week after we receive your order. If you provided an email address we will notify you when your order is shipped. Complete installation instructions & a guarantee and warranty card comes with all devices. Please call, visit our website, or email dave@clearwater-gmx..com if you have any installation or configuration questions.

Clearwater GMX is a Factory Authorized Distributor of
the GMX Water Softening and Conditioning System.