ORDER FORM
(USA and Canada Only)
Instructions:
* Print this form. | * Or MAIL to:
* Fill out completely | Futrex, Inc.
* FAX to: 1-240-242-3980 | 130 Western Maryland Pkwy
* Or call 1-240-242-3980 | Hagerstown, MD 21740
Ship to: __________________________ Bill to: _________________________
__________________________ _________________________
__________________________ _________________________
Credit Card Type: [ ] VISA [ ] MasterCard [ ] Ship via C.O.D.
(check one)
Card number: |_______| |_______| |_______| |_______| Expiration: ___/___
3 Digit Security Code: _______
Item Price/ea Quantity Total
Futrex 1100 $99.50 ________ ________
Sales Tax (add 6% ________
if shipping to MD)
Shipping ($14.00 ea) ________
Total ________