772 Mullet Dr., Cape Canaveral, FL 32930 USA - FAX 407-396-2242
| Instructions: |
| 1. Print this order form. |
| 2. Complete all sections. |
| 3. Fax or mail this form to the fax # / address listed above. |
Ship To:
Name:____________________________________________E-Mail:____________________________________
Address:____________________________________________________________________________________
City:_____________________________________ State/Province____________________ Zip________________
Country______________________ Telephone: (_______)_______________________________
|
Quantity |
Description |
Price Each |
Total |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| Subtotal | $______________ | ||
| Method of Payment: | Shipping | $______________ | |
| (circle one) | VISA - MC - Check | Total | $______________ |
Credit Card #:_______________________________________________ Exp. Date:_______________
Signature: ___________________________________________________________