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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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Ribbons for Amano Pix 55 (2 to 5 ribbons)
Quantity Ordered_____Price Each $11.00 Total __________ Ribbons for Amano Pix 55 (6 to 9 ribbons)
Quantity Ordered_____Price Each $10.00 Total __________ Ribbons for Amano Pix 55 (10 to 35 ribbons)
Quantity Ordered_____Price Each $9.00 Total __________ Ribbons for Amano Pix 55 (36 or more ribbons) Quantity
Ordered_____Price Each $8.50 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]______ Cardholder Name:_________________________________________________ Card Number:_____________________________________________________ Exp Date:_________________ Signature:________________________________________________________ Date:_________________ |
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