Cust. No:___________________________ Name:_____________________________ Address:___________________________ City/State:__________________________ Zip:_________Phone:_________________ |
Name:________________________________ Address:______________________________ City/State:_____________________________ Zip:_________Phone:____________________ |
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Sub Total |
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N.Y. Residents add 9% Sales Tax |
N.Y. Tax |
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Haz-Mat Fee $17.00 If (applicable) |
HM Fee |
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UPS Shipping & Handling |
Shipping |
__________ | |
TOTAL |
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()Personal Check ()Money
Order ()COD (Cash Only) _____________________________________
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Credit Card Information:. VISA
MasterCard (circle one) Account Number:______________________ 3 Digit Card Code (On Back) ________ Expiration Date:___/___/___ Phone:______________ Card Holders Signature: ______________________________________________ Please Print Name as appears on card: _____________________________________________ |