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
         
          
         
         
         
         
         
         
           
         
          
         
Method of Payment
"
MasterCard " Visa " America Express                 " Check or Money Order

__________________________________       ____________________
Charge Card Account Number                                  Expiration Date
_________________________________
Signature

TOTAL PRICE OF ITEMS  
SHIPPING AND HANDLING  
TOTAL  
Shipping Address (if it is different from above):

 

 

AC Diagnostics, Inc., 1131 W Cato Springs Road, Fayetteville, AR 72701, USA. E-mail: infor@acdiainc.com. Tel: (479) 595-0320