Name:__________________________________

Company:_______________________________

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Address:________________________________

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Name:__________________________________

Company:_______________________________

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Ribbons for Amano Pix 21  (2 to 5  ribbons) Quantity Ordered_____Price Each $11.00 Total __________

Ribbons for Amano Pix 21  (6 to 9  ribbons) Quantity Ordered_____Price Each $10.00 Total __________

Ribbons for Amano Pix 21 (10 to35  ribbons) Quantity Ordered_____Price Each $9.00 Total __________

Ribbons for Amano Pix 21 (36 or more ribbons) Quantity Ordered_____Price Each $8.50 Total ________

Amano Pix 21 ..... KEYS  ...............................Quantity Ordered_____Price Each $5.00 Total ________

Shipping (flat rate continental U.S.A shipments)______________________________________$7.50

PA State  6% Sales Tax (PA SHIPMENTS ONLY) ____________________________Total_____________

Charge to my: [MasterCard]____[Visa]____[Discover-Novus]____[American Express]______

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Date:_________________