Pitrone & Associates Fax Order Form

Digital D254B & D404B Clock Order Form

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 8:30AM to 5:00PM 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:________________________________

2.5" Digital Wall Clock Model # D254B (s)...Quantity Ordered_______Price Each $89.00 Total__________

4" Digital Wall Clock Model # D404B (s).....Quantity Ordered_______Price Each $169.00 Total___________

Shipping prices continental U.S.A shipments.................$10.95 (1 clock)....$15.95 (2 clocks)
$20.00 (3 clocks)......$25.00 (4 clocks)
Shipping ( continental U.S.A shipments)__________________Shipping Charge __________

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:________________________________________________________

Date:_________________

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