Disinfect & Fog Agent Form - Purchasing Foggers
Complete the form below, and we will invoice the client.
AGENT Name: *
AGENT Email: *
Client Business name:
Client name: *
Client Email: *
Client Phone number: *
Client Shipping Address: *
Client City, Province, Country: *
Client Postal code: *
Type of Business: *
Select one...
Automotive
Business
Child Care
Community Centre
Dental
Education
Entertainment
Funeral Home
Government
Healthcare
Hospitality
Industrial
Place of Worship
Real Estate
Sports + Recreation
Transportation
Tourism
Travel
Veterinarian + Animal Care
Other
If other, enter Below:
Payment method: *
Select one...
Credit Card
Cheque
E-Transfer
Client Billing Address (if different from shipping address):
What product(s) do they want?
Disinfecto Cordless Electrostatic Sprayer
Mini Thermal Fogger
Cordless ULV Atomizer
Nano Atomizer
Portable Fogger
'Big Blue' ULV Fogger
Hurricane Fogger
Heavy Duty ULV Fogger
Industrial Fogger
Extra Canister - Nano Atomizer
Extra Battery - Portable Fogger
Mini Nano Personal Sanitizer Sprayer
SaniGO Bands
What Solution do they want?
Ultra-Lyte 4 Litres
Ultra-Lyte 16 Litres
Environize 1 Gallon
Environize 4 Gallons
Vital Oxide 1 Gallon
Vital Oxide 4 Gallons
Pricing discussed with client: *
Additional information (optional):
Thank you!
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