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

USA Order Form

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

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

  Size:  1/4"   OR   3/16"      Quantity:                       $ ________/thou       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)  
Exp. Date: ( mm/yy )  
Amount approved
( before shipping charges )***		  
Name on card:  

Address of Card Holder:
 

  

Freight FOB Georgia, USA   UPS/US Post Freight calculated when shipped.