ORDER FORM
(USA and Canada Only)
Instructions:
* Print this form. | * Or MAIL to:
* Fill out completely | Futrex, Inc.
* FAX to: 1-301-670-1103 | 6 Montgomery Village Ave.
* Or call 1-800-255-4206 | Suite 620
| Gaithersburg, MD 20879
Ship to: __________________________ Bill to: _________________________
__________________________ _________________________
__________________________ _________________________
Credit Card Type: [ ] VISA [ ] MasterCard [ ] American Express
(check one) [ ] Discover [ ] Ship via C.O.D.
Card number: |_______| |_______| |_______| |_______| Expiration: ___/___
Item Price/ea Quantity Total
Futrex 1100 $99.50 ________ ________
Sales Tax (add 5% ________
if shipping to MD)
Shipping ($13.00 ea) ________
Total ________