INFORMATION REQUEST Please fill out and submit the following form Company Name Your Name Company Address Company Phone Number and Extension Your Email Address Company Fax Number What can we do for you? Would you like to place an order? If so, please provide the following information: Rhodes Part # Qty Brief Description Price Method of Payment: Purchase Order Visa MasterCard American Express COD PO #: TERMS Net 30 days with approved credit and open account $50.00 minimum order $100.00 minimum order to open new account We will prepay and add freight/delivery charges to your invoice When would you like to have your order? Rush/Hotshot Normal Delivery

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8930 Lawndale, Suite D, Houston, Texas 77012   OFFICE: 713-926-2229 FAX: 713-926-6700 EMAIL: service@rhodesenvironmental.com