| Billing
Information |
Shipping
Information |
| Name: |
Name: |
| Company: |
Company: |
| Address: |
Address: |
| City: |
City: |
| State: |
State: |
| Country: |
Country: |
| Zip Code: |
Zip Code: |
| Phone Number: |
Phone Number: |
| Fax Number: |
Fax Number: |
| Email: |
Email: |
|
|
| Item: |
Quantity: |
Price
Each: |
Total
Amount: |
| 1. Model 175 |
___________ |
$299.00 |
___________ |
| 2. Card Rack 12 pocket |
___________ |
$28.00 |
___________ |
| 3. Card Rack 25 pocket |
___________ |
$30.00 |
___________ |
| 4. Ribbon |
___________ |
$14.00 |
___________ |
| 5. Weekly
Cards (per 1000) |
___________ |
$34.00 |
___________ |
| 6. Bi-Weekly
Cards (per 1000) |
___________ |
$34.00 |
___________ |
| Card
Holder Name: |
| Card
Number: |
| Exp Date: |
| Signature: |
| Date: |
| Payment
Type: MasterCard[ ] Visa[ ] Discover[ ] American
Express[ ] |
| Purchasers in
NC add tax. |
| For all
purchases UPS Ground added. |