8 F.J. Clarke Circle
Bethel, CT 06801
P.O. Box 308
Tel: 800-243-6144


Directions:
1. PRINT OUT THIS PAGE & FILL OUT
    (Yellow Sections are Optional)
2. FAX ORDER TO: 800-962-8345 OR MAIL
    ATTN: CUSTOMER SERVICE

Company Name  
Your Name  
Email Address  
Account #  

BILL TO:   SHIP TO:  
Name   Name  
Address   Address  
Address   Address  
City   City  
State   State  
Zipcode   Zipcode  
Phone   Phone  

Payment type Credit Card Number Exp Date CCV
MC / VISA / AMEX      

Ship Method (Please Circle)
Desired Ship Date
UPS Overnight / 2nd Day / 3 Day / Ground

Quantity Item# Item Description
Unit Price
Total
         
         
         
         
         
         
         
         
         
         
         
  Total  


Special Instructions/Comments: