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Name:__________________________________ Company:_______________________________ Address:________________________________ Address:________________________________ City:________________________State:______ Country:___________ZipCode:_____________ Phone Number:__________________________ Fax Number:____________________________ E-Mail:________________________________ |
Name:__________________________________ Company:_______________________________ Address:________________________________ Address:________________________________ City:________________________State:______ Country:___________ZipCode:_____________ Phone Number:__________________________ Fax Number:____________________________ E-Mail:________________________________ |
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12to 35 ribbons Quantity
Ordered
_____Price Each $8.00 Total ____________ 36 or more ribbons Quantity
Ordered _____Price Each $7.50 Total ____________ Pix 21 KEYS
............. Quantity
Ordered _____Price Each $5.00 Total ____________ Shipping (flat rate continental U.S.A shipments)_______________________$8.95 PA State 6% Sales Tax (PA SHIPMENTS ONLY) ____________ Total_____________ Charge to my: [MasterCard]____[Visa]____[Discover-Novus]____[American Express]______ Cardholder Name:_________________________________________________ Card Number:_____________________________________________________ Exp Date:_________________ CVV Code:________________ Signature:________________________________________________________ |
