Order
Form
Home Page
To place an order, you may call us at
800-778-0508 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:_______________________________
E-mail_________________________ Phone:(___)____________
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 |
$ | ||
|
Shipping in Continental United States |
|||
|
Shipping to Canada add $ 10.00 |
|||
|
TOTAL |
$ | ||