Please fill out the information below then print this page and fax your order to Loctite®.

Equipment Services Group
Loctite Corporation
1001 Trout Brook Crossing
Rocky Hill CT 06067
Phone: 860-571-5100
Fax: 860-571-5131

Subject: Equipment Order

Customer Information:

Contact Name:
Company Name:
Street Address:
City, State, Zip Code:

Payment Method:

Option1: Direct Account With Loctite. Attach Purchase Order With This Form.

Purchase Order Number:

Option 2: Credit Card (Visa or Mastercard)

Name (As Shown on Card):
Card Type:
Card Number:
Expiration Date:

Order Information:

Item Number Description Unit Price Qty Shipping Total Price