Order Form                                                                                 Home Page
To place an order, you may call us at 800-708-APURE  OR print off this page and fill out the order form, which may be faxed to 517-367-8888 , or mail it along with your payment. Mail to: 1305 S. Cedar St. Suite 103 Lansing, MI 48910

Thank you for the order.

Name:_______________________________Phone:(___)______________

Company:________________________ E-mail_________________________

Street Address:_____________________________Fax:   (__)_____________

City:______________________________State:________ Zip:___________

If paying with Credit Card   () Visa     ()MasterCard     ()Discover

Card#_____________________ Exp. Date_________________

Name on Card:________________________________________

Signature_____________________________________________

Item (Product Name and/or Number):  Quantity: Unit Price: Amount:
    $ $
    $ $
    $ $
    $ $
    $ $
    $ $
    $ $
    $ $
    $ $
    $ $
    $ $
    $ $

SUBTOTAL

 $

FREIGHT in Continental United States 

  

FREIGHT to Canada add $ 10.00

TOTAL

 $

Please make check payable to and mail to:
Success Apure Products
1305 S. Cedar Suite 103
Lansing, MI 48901

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