Pitrone & Associates Fax Order Form

TCX 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 TCX 21 timeclock(s)....................... Quantity Ordered_______Price Each $279.00 Total_________

Amano TCX 21ribbon(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 ... $14.00 two clocks ... $18.00 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:_________________