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

Order Form - Canada ( English)

 Fill in and Fax to 1-800-826-8912

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

Size:       1/4"        3/16"        5 mm            Quantity _________     Minipak _____ 
    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 Extra : F.O.B. - CHARLTON, ON  

UPS / Canada Post / Purolator

TAXES: GST/HST EXTRA - TERMS:   VISA / MASTERCARD / OAC
MAKE CHEQUES PAYABLE TO:  BLACK BRIDGE ONLINE INC.