To place an order print this form, complete, and fax to 1-519-836-0388
Customer / Shipping Information (please print clearly)
Name:__________________________ Job Title:___________________________
Company:________________________ Address:__________________________
City:____________________________ State/Province:______________________
Zip/Postal Code:___________________ Country:___________________________
Phone:__________________________ Fax:______________________________
Email:____________________________
Order Information
| Product | Price (US dollars) | Shipping & Handling * | TOTAL | |
|
$399.00 |
$ | |||
| TOTAL | $ |
* $15 in USA / Canada for overnight delivery; $45 for Overseas delivery
Payment Information
___ Please issue me an invoice
___ Charge my: ____ Visa ____ Mastercard
Card Number:_______________________________ Exp. Date:________________
Name on Card:________________________________________________________
