3 Logan Road -- Nashua, New Hampshire 03063-2213
Order toll-free at 1-800-997-2337
FAX (603) 882-2586 

Billing and Shipping Information:



Name(as it appears on credit card):______________________________________________



Ship to (if different from card holder):________________________________________


Company:___________________________________________


Street:____________________________________________


City:______________________________________________  State:_________  Zip:_________



Country (if other than USA): ________________________________________

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   Catalog #               Description               Qty  x Price Each  = Extended


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_______________    ____________________________     _____   __________    _________



_______________    ____________________________     _____   __________    _________



_______________    ____________________________     _____   __________    _________



_______________    ____________________________     _____   __________    _________



_______________    ____________________________     _____   __________    _________
Standard Shipping Charge
Range
Charge
$0 to $15
$9.95
$15+ to $30
$13.75
$30+ to $50
$15.95
$50+ to $75
$16.50
$75+ to $100
$18.25
$100+ to $150
$23.25
$150+ to $200
$24.95
$200+  to $300
$27.50
$300+ to $400
$29.50
$400+
$35.25
Subtotal: _________
Shipping: _________
Total: _________
 
                                                                 


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Card #:_________________________________________________ Exp. Date:________

                                                                     mm/yy

Signature: _____________________________________________



Payment: ___ MC      ___ VISA        ___Discover  



Phone Number (in case we have questions about your order):



(______) ________ - ___________ (best time to call: __________   Time zone: _______) 



email* :___________________________________________



*Include your email address and we'll send you a note when your order is shipped.