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

USA Order Form

Print Out, Fill in and Fax to 1-888-600-0408

 Company Name:  
 Contact:   
 Email Address:  
 Address:  
 City:   
 State:  
 Zip Code:  
 Telephone:

  Size:  1/4"       3/16"       5 mm           Quantity:                         Minipak:            

Purchase Order Number: (if necessary ) 
 Shipping Method (please circle):        Mail        UPS       
 Date Requested:   
Card Type: (please circle)

             VISA                MasterCard          

Card Number:

(1111 2222 3333 4444)

  
CVC Code: ( XXX )  
Exp. Date: ( mm/yyyy )  
Amount approved
( before shipping charges )***		  
Name on card:  
Address of Card Holder:  

Signature:

 

Freight FOB Georgia, USA  

UPS/US Post Freight calculated when shipped.