Dainichi Cichlid Food Order Form

CICHLID ORDER FORM

Fill Out Order Form and SUBMIT by E-mail

or Select PRINT on your Web Browser and FAX or MAIL to:

580 N Berry Street
Brea, CA 92821 USA
Tel 714.672.0855 • Fax 714.672.0852

For information or comments please contact us: Email info@dainichi.com or Toll Free 877.366.3434 (FOOD-4-FISH)

(Customer Information
First Name
Last Name
	Existing Customer (Input Changes Only)
	Note: E-mailed Final Invoice also serves as your Order Confirmation.
E-mail	Required
Phone	Alt Phone Include Area Code
Bill To Street Address
Bill To City / State / Zip	City State Zip
Bill To Foreign State / Country	Foreign State Country

Ship To Customer Information	Same as "Bill To" (Skip "Ship To")
Ship To Street Address	If different from "Bill To"
Ship To City / State / Zip	City State Zip

Notify you of specials or new products?
How did you hear about us?
Payment Method
Credit Card Number	Exp Date Month Year
Credit Card Security Code	CVC Code 3 Digit No. on Signature Panel (Required for New and Repeat Orders)

CICHLID FOOD
QTY	FORMULA	PELLET TYPE	PELLET SIZE	BAG SIZE & PRICE	TOTAL
	XL Pro	Floating
	XL Pro	Sinking
	Ultima Krill	Floating
	Ultima Krill	Sinking
	Color Supreme	Floating
	Color Supreme	Sinking
	Veggie Deluxe	Sinking
	Veggie Deluxe	Sinking
	Veggie FX	Sinking
	Veggie FX	Sinking
	Color FX	Sinking
	Color FX	Sinking
			SUB-TOTAL (EXCLUDES Shipping & Tax)*

*7.75% Sales Tax: California Residents Only.

SHIPPING & HANLDING

Default Shipping: UPS Ground

Up to 1.1 lb (Cheapest Way)	Priority Mail	$6.00
International / AK / HI / PR	Priority Mail	Weight Dependent
All Orders Greater Than 1.1 lb	UPS Ground	Weight Dependent

Questions, Comments or Special Requests