Pitrone & Associates Fax Order Form

Bell Ringer Model DWA-H "Work Alerter"

Print and Fax to: 215.674.9338

or mail to:

Pitrone & Associates

9 Park Avenue

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:________________________________

Bell Ringer DWA-H ........Quantity Ordered_______Price Each $389.00 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:_________________