Amano Pix 21 Fax Order Form

PIX 21 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 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 Pix 21 timeclock(s)...........................Quantity Ordered_______Price Each $239.00 Total_________

Amano Pix 21 ribbon(s)................................Quantity Ordered_______Price Each $11.00 Total __________

Time Cards #K1400HB..(500 per pack).......Pack(s) Ordered_______Price Each $20.00 Total __________

Shipping costs... $10.00 one clock ... $15.00 two clocks ... $19.00 three clocks ... Shipping Total ________

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:_________________