Indium APW 1/2 oz, pack of 24 .. Price $288.00 ... Qty ________ Sub-total $ _____________

Indium APW 1 oz, pack of 6 ..... Price $198.00 ... Qty ________ Sub-total $ _____________

Indium APW 1 oz, pack of 12 .... Price $288.00 ... Qty ________ Sub-total $ _____________

................................................................... Total $ _____________

Shipping address/contact

Name _______________________________________________________________

Address ____________________________________________________________

City __________________________________ State ______ Zip ___________

Phone ______________________ Email _________________________________

Credit card information (if applicable)

Credit card type _________________

Credit card number ______________________________ Exp Date _________

Name ____________________________________ Phone ____________________

Address ____________________________________________________________

City __________________________________ State ______ Zip ___________

Method of payment (payable to Essentail Health, INC.)

____ Check ____ Money order ____ Credit card

Mail to

Essential Health, Inc. PO Box 1343 Morrisville, PA 19067-0343

fax: 435-514-5239

orders: 800-737-6509

questions: 435-514-5239