Company or personal Information:

Sales Dist. 7710. Flooring dist 7720 Retail flooring Co 7720 Appliance dealer7720 Appliance installer7720 Other:

For office use:
Distributor reference #

Company Name: Your Name first and last:

Address: City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip:

Home Phone:

Business Phone:

Approx. how many MM would you like to order: 1 20 40 60 80 100 200 300 400 500

E-mail address

Shipping Address:

Name:

Address:

City:

State: AK AL AR AZ CA CO CT DC DE FL GA HI AI ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA IA SC SD TN TX UT VA VT WA WI WV WY

Please fill in this form and fax it back at 913 381-2906 or press the Submit button.

Please read the instructions and familiarize yourself with the operation of the Moisture Minder®.
You will avoid unnecessary calls and questions from your customers.
We also have a 12 months limited warranty which is fully outlined in the instruction sheet.
Terms and Conditions:
- First order requires credit card payment or prepaid check.
- Net 30-day terms may be extended after the first order pending a credit check.
Upon receipt of this information we will send you a password to open and purchase the Moisture Minder® from the dealer side shopping cart at discounted prices.