
Fax Pages 1 & 2 to 772-223-4040
Business Name_______________________________________________
Your Name: _________________________________________
Email address __________________________________________ Would you prefer your invoice E mailed? ________
Shipping Address: _____________________________________________
Shipping Address 2: ____________________________________________
City: ___________________ State : ___________________ Zip Code: _______________
Phone with area code: _______________________ Ext _______ Fax w/ area code___________________________
Payment: Credit Card Visa, MasterCard or American Express
Card # ___________________________________________ Expiration: ___________________
Complete name or names on the card ________________________________________________________________
Card Code (3 digit on back of Visa or MC or, 4 digit on front of Amex) _______________
If using PO# :___________________________________ Schools, Government or Pre Approved only
Billing address if DIFFERENT
Business Name_______________________________________________
Contact Name: __________________________________________________
Billing Address: ______________________________________________
Billing Address 2: ____________________________________________
City: ___________________, State : ___________________ Zip Code: ________________
Phone with area code: ____________________________ Fax with area code________________________________
Fax pages 1 & 2 to 772-223-4040 Call us with questions 800-321-5716
Notes, Comments or Questions:
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Order Form Page 2
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P.O. Box 2472, Palm City, FL 34991
Local & International 772-223-5511
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