ORDER A PRODUCT

There are three ways to order the item(s) that you want. 1) Complete the form and submit it. We will contact you to obtain billing information. 2) You may print the form, write your credit card name, number and expiration date on it and fax to 919-380-2181, 3) you may call 1-800-786-9889 toll free to speak with us.

First Name
Last Name
Company
Position
Street Address
City
State	Postal Code / Zip
Country:
Phone
Fax
Email

PRODUCT INFORMATION

Product Name
Price	Quantity
P.O. #

BILLING INFORMATION (if different from above)

Name
Street Address
City
State	Postal Code / Zip

Credit card information should be faxed or mailed. We ask that you do not submit this email reply form with credit card information. Your web browser should not allow you to enter information into these fields. Please FAX this form to us after submission. Please print this form page then fill in the credit card fields manually before faxing.

Card number
Name on card
	Expiration date
	Month: Year:

	Be sure to print this form before pressing "SUBMIT"

Shipping is via UPS ground service unless otherwise requested. A shipping and handling charge will be added to your total order.