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ORDER
FORM
Name
Company
Address
City
State
Zip-Code
Country
Phone
Fax
E-mail
P.O. Number
CATALOG
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QUAN-
TITY |
DESCRIPTION |
UNIT
PRICE |
TOTAL |
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Method of
Payment
"
MasterCard "
Visa "
America
Express
"
Check or Money Order
__________________________________
____________________
Charge Card Account
Number
Expiration Date _________________________________
Signature |
TOTAL PRICE OF ITEMS |
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| SHIPPING AND HANDLING |
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| TOTAL |
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| Shipping Address (if it is
different from above):
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AC Diagnostics, Inc., 1131 W Cato Springs Road, Fayetteville, AR 72701, USA. E-mail:
infor@acdiainc.com.
Tel: (479) 595-0320
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