Request Form

This request form is not a secured order form. This form is for placing an order request only and will not handle any transactions. Do Not include any credit card numbers or account information in this form.

After placing your order or submitting a question, press the "Submit" button and someone from Brine Shrimp Hawaii will contact you.

Mahalo !

LIVE HAWAIIAN GROWN FOOD
	Qty	Item	Price
1		Brine Shrimp Wholesale pricing available for retailers (brine shrimp only). Contact us for more information. Federal ID No. and State Tax License required.	$20/cup
2		Blood Worms	$15/cup
3		Daphnia (reg.)	$25/cup
4		Daphnia (micro)	$25/cup
5		Feeder Fish (sm & med)	10 for $1
6		Feeder Shrimp (freshwater opae)	10 for $1
AQUARIUM PLANTS
7		Anacharis	$.60
8		Foxtail	$.60
9		Green Hedge	$.60
10		Calico Hedge	$.60
11		Krinkle	$.95
12		Ludwigia	$.60
13		Mondo Grass	$.95
14		Mushroom	$.60
15		Myrophillium	$.60
16		Palm	$.95
17		Sandriana	$.95
18		Star Plant	$.60
19		Tarrow	$.95
20		Teardrop	$.60
21		Temple	$.95
22		Vallesneria	$.95
23		Water hyacinth	$.60
24		Water lettuce	$.60
25		Duckweed	$1 per cup

(Shipping and Handling varies depending on location. Delivery on Oahu available.)

Please fill out the following. Required fields are marked with an asterisk (*).

First Name*	Last Name*
Address*
City*	State* Zip*
Country*
Phone*	() - Alt. Phone () -
Fax	() -
E-mail Address*

Comments or Questions
ALOHA!

You may also E-mail us at brineshrimphi@hotmail.com

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