Instant Road Repair® Order Form

We have created this form to give our customers just one more way to easily obtain our products. If you’re paying by credit card, please call 281-441-3558 or leave a call back phone number so that we can acquire card number and expiration date. Instant Road Repair comes in 50 pound plastic resealable buckets.

In the “Special Instructions” area please specify any special requirements or questions that you may have and our customer service staff will contact you.

DO NOT include any credit card information on this form!

Your Name (required)

Your Email (required)

Your Telephone (required)

Your Fax

Your Address (required)

Your City (required)

Your State (required)

Your Zipcode (required)

Your Country

I would like to order # of pallets of Instant Road Repair:


Special Instructions: