Pitrone & Associates Fax Order Form

PIX3000X 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:________________________________

Amano PIX3000X timeclock(s)....................... Quantity Ordered____Price Each $379.00 Total_________

Amano PIX3000X ribbon(s)........................ Quantity Ordered______ Price Each $10.00 Total __________

Shipping costs... $12.00 one clock ... $19.00 two clocks ... $24.00 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:_________________