FRESH-CHEMCO

REFERRAL:			          REFERRED BY:

Company			    Zip	          #1 Name		        Phone
___________________________________       ___________________________________
Business			          #2 My Favorite Charity
___________________________________       ___________________________________
Contact			    Phone         #3 Company
___________________________________       ___________________________________
                                          
Title			    Dept.         Mail Referral Payment to:  #1 #2 #3
___________________________________       (Please circle choice)
Relationship:			          
Business Assoc.	________	          Mail to Address:
Friend		________	          __________________________________
Relative	________	          Street
Customer	________                  __________________________________
Sub-Contractor	________                  City, State, Zip
Other		________                  __________________________________
============================================================================
Below to be completed by FRESH-CHEMCO

Initial Order Date	___________  Referral Receipt Date	____________
Initial Order PO#	___________  Initial Order Value	____________
Initial Order Value	___________  Initial Order Ref. Fee (10%) __________
Initial Order Rebate (10%) ________  Referral Fee Send Date	____________
Rebate Send Date	___________
============================================================================

This form may be duplicated for additional referrals.
Referral forms may be faxed to 412-460-0166 Attn. Keith Brody

HERE IS HOW IT WORKS:  Fax (or mail) us this form with information
about yourself and your referral. Be sure to circle #1, #2 or #3 for
payment. On the referral’s initial purchase they will be given a
10% rebate and a 10% referral payment will be sent to you.

Questions and requests for information may be mailed to fresh@nauticom.net