Seacurefill™ Order Form
 

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To print this form, click on the Print button in your browser.

  
 

To order by phone, call us at (978) 342-9600,  9-5 EST, or print order form and fax to (978) 348-1110, or send with your check to Seacurefill LLC, 291 Westminster St., Fitchburg, MA 01420-3765
 

 Size

 Seacurefill Unit

Price

QTY

Total

1˝" 

Includes quick connect fitting, 30" of 5/8" clear hose, adapter and cap

$ 40.00

    

2"

Includes quick connect fitting, 30" of 3/4" clear hose and cap

$ 56.00

    

1˝" 

Caps  Brass, Chrome, Red, White, Blue, Yellow, Green, Black (Circle Choice)

$24.95

    

2"

 Caps Brass, Chrome, Red, White, Blue, Yellow, Green, Black (Circle Choice)

$28.95

    

Subtotal

  

MA residents add 5% sales tax

  

Shipping  Charge: Best Way Cost by Agreement and Packaging Used-CALL!

  

Grand Total

  


CUSTOMER INFORMATION
First Name:  
Last Name:  
Company:  
Address:  
City:  
State:  
Zip:  
Phone Number:  
Fax Number:  
E-mail:  


PAYMENT INFORMATION
Payment Type:

Visa

 AMEX

Master Card

  

Check

  
Credit Card Number:  
Credit Card Expiration:  
Card Verification Value:
(The last three digits found on signature strip on back of card.)		  
Name As Appears On Card:  
Bill to Address on Credit Card:
 
Signature:
Special orders or shipping instructions:

 

 

PLEASE TELL US ABOUT YOUR BOAT
Builder:  
Model:  
Year:  
Size:  

 

Thank you for your order.

Seacurefill LLC, 291 Westminster St., Fitchburg, MA 01420-3765

Tel: 978-342-9600, Fax: 978-348-1110, Email: Seacurefill@comcast.net

Page Updated 8/6/2007