(Fax, Mail Or Phone)
fields marked with an asterisk (
*
) are mandatory
570 Upper James St.
Hamilton, ON L9C 2Y7 Canada
P: 905-389-2616
F: 905-389-2616
PST#
GST#
*
Date:
(eg. Sep 1, 2001)
Billing Information
(same as credit card bill)
Shipping Information
-
check if same as billing
*
Name:
*
Name:
*
Street:
*
Street:
*
City:
*
City:
*
Prov./State:
*
Prov./State:
*
Postal/Zip:
*
Postal/Zip:
*
Phone #:
*
Phone #:
Order Information
Product Number
Quantity
(meters)
Price
(meters)
Net Total
Product Number
Quantity
(meters)
Price
(meters)
Net Total
1
8
2
9
3
10
4
11
5
12
6
13
7
14
Credit Card Info
Payment Summary
Name:
NET TOTAL:
(as it appears on card)
(All Applicable Taxes and Shipping Are Extra)
Card / Method:
FAX
PHONE
Shipping Method:
(i.e UPS, Pickup, etc)
Card #:
Expiry:
