TM
Patent  U.S. # 5317853 / CAN. # 2115722

Order Form - Canada ( English)

Due to US$/Cdn$ Fluctuations ......Please call for Pricing .... 1-800-826-8912           

Print Out, Fill in and Fax to 1-800-826-8912

 Company Name:
 Contact: 
 Email Address:
 Address:
 City: 
 Province:
 Postal Code:
Telephone:

Size:    1/4"    OR    3/16"                                    Quantity:                       Minipak:  ______            (please circle)
    Purchase Order Number:      
   Ontario PST Exemption #            
 Shipping Method (please circle):        Mail        UPS    Other:                          
 Date Requested:                                
Card Type: (please circle)

VISA       MasterCard   

Card Number:                            (1111 2222 3333 4444)   
Exp. Date: ( mm/yy )  
Amount approved
( before shipping charges )***		  
Name on card:  
Address of Card Holder:
 		  

Fax to 1-800-826-8912

 FREIGHT: F.O.B. - CHARLTON, ON   -   UPS / Canada Post    Freight calculated when shipped.                    TAXES: PST(Ontario) and GST EXTRA - TERMS:   VISA / MASTERCARD
MAKE CHEQUES PAYABLE TO:  BLACK BRIDGE ONLINE INC.