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Order Form

Please print this page, fill out and mail with payment.

SHIP TO:

Name:                                                   

Address:                                                

City:                                                     

State:                                            Zip Code:                    

Telephone number:     (     )                    

e-mail:                                                   

Mail in Order Form

QTY

PART NUMBER

DESCRIPTION

UNIT PRICE

TOTAL PRICE

         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
Please see shipping information on shipping page. 

 Insurance is $.80 per $100.00 of purchase and is always recommended.

SUBTOTAL

 

N.Y. Resident sales tax

 

SHIPPING

 

INSURANCE

 

TOTAL

 
 

 

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