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Order Form to Fax

  Date _________________________

Payment Method:  If using a purchase order from the school, you need to fax , send or e-mail it with your order. 

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Credit card # _____________________________________________, Expiration date___________.

Last 3 #'s on back of credit card______________

Ship To:  
Attn:  
Address  
City, State, Zip Code  
Address where credit card statement is sent  
City, State, Zip where credit card statement is sent  
Fax #  
Day Phone  
Best time to call  
Home Number  
e-mail address  
Special Instructions  

 

Quantity Ordered Description Unit Price $ Amount
       
       
       
       
       
       
       
       
       
       
       
       
       
       
 

 

    

Signature:_______________________________________________________________________     Date _________________________

Fax:  888 530-7654      
or 636 536-0722
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