Pitrone & Associates Fax Order Form

Amano PR600 Watchman's clock

Print and Fax to: 215.674.9338

or mail to:

Pitrone & Associates

P O Box 711

Hatboro, PA 19040

Any questions call 215.956.9797 9:00AM to 4:30PM EST Monday - Friday

Billing Information

Name:__________________________________

Company:_______________________________

Address:________________________________

City:________________________State:______

Country:___________ZipCode:_____________

Phone Number:__________________________

Fax Number:____________________________

E-Mail:________________________________

Shipping Information

Name:__________________________________

Company:_______________________________

Address:________________________________

City:________________________State:______

Country:___________ZipCode:_____________

Phone Number:__________________________

Fax Number:____________________________

E-Mail:________________________________

Amano PR600 Watch clock Quantity Ordered_______Price Each $439.00 Total_________

Station Key (s)....................Quantity Ordered_______Price Each $16.00 Total ___________

Station Box (s)....................Quantity Ordered_______Price Each $20.00 Total ____________

Box of tape(s)......................Quantity Ordered_______Price Each $20.00 Total __________

Shipping (flat rate continental U.S.A shipments)______________________________$10.00

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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