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Order Form

To place an order with CeraTech Media fill out the form below and submit. Be sure to include your phone number so we may contact you to confirm order and collect payment information.

Download our Fax Order FormIf you would prefer to order by phone, call us toll-free at 866-719-4682 in the USA, Canada, and Mexico or dial 270-965-6207. Or if you would prefer to order by fax, download our fax order form, fill it out by hand or electronically within Adobe Acrobat Reader then print and fax to 270-965-2901.

Payment options include credit card (Visa, Mastercard and American Express accepted) or direct billing. If you select Direct Billing in payment options and you do not have an account with us, we will set one up when we contact you by phone.

Note: All media must be ordered in increments of 50 lbs. Size of order may require alternative shipping option. If this is necessary, we will contact you before filling the order. Compounds may be ordered in increments of 5 gallons. (Available in 5 gallon and 55 gallon containers.)
 
Customer Information
Company Name
Contact Name
Address 1
Address 2
City
State or Province
Postal Code
Country
Phone Number
Fax
Email Address


Your Order
Please note: There is a $4/box handling fee for orders 300 lbs. or less.

Purchase Order Number (optional)


Shipping Information
Check if same as customer address/phone above.
Shipping Name
Shipping Address 1
Shipping Address 2
City
State or Province
Postal Code
Country
Shipping Phone Number


Ship Date if not immediately (optional) - mm/dd/yyyy
Preferred Shipping Method
Your UPS Account Number (optional)
Enter this if you are shipping UPS and would prefer
to have shipping billed to your UPS account.


Billing Information
Visa accepted Mastercard accepted American Express accepted or Direct Billing
We will contact you by phone to collect payment information.


Other
How did you hear about us? (optional)
Questions/Comments (optional)
 
  
UPS Tools to Assist Our Customers
 
 
UPS Shipping Rates
This tool will provide you with estimated shipping costs for each 50 lbs. box coming from CeraTech Media. Five (5) gallon compound containers weigh approx. 45 lbs.
  DESTINATION
Country:  
City:  
Postal Code:  
Ship Date:  
(Format YYYY-MM-DD)
 
  PACKAGE INFORMATION
UPS Service:  
Customs Value:   Required for international shipments only
 
 
 

 
UPS Package Tracking

Please enter up to five UPS Tracking Number(s) you wish to track:





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