Phone: 905-738-4017 or Toll-free 800-387-7029
Fax: 905-738-2486 or Toll-free 800-452-2128

(Print this form, complete and fax to us)

CUSTOMER INFORMATION:
Name:				Date:
Company:
Address:				Apt/Suite/Unit:
City:		State/Province:		Zip/Postal Code:
Phone (Office):	(        )		Phone (Home):	(        )
E-Mail Address:			Phone (Fax):

Social Security Number (required by U.S. Customs): ***Why is this required?***
Federal Tax ID Number (businesses only):

Specify:

Heater Model:

CW-S

CW-M

CW- STL

FM

FM-STL

Heater Suffix:

Voltage:		240 volt		208 volt		Other ________ volts
Phase:		Single (1)		Three (3)
Note: 240 volt - single phase, is standard for residential heaters
Control:		TPT3		EPC-9
Heater is:		New installation		Replacement unit

METHOD OF PAYMENT:
	Visa		Mastercard
Card Number:

-

-

-

Expiry Date: ______ /______
Card Holder Name:		Signature:

 

BASE PRICE:	$
OPTIONS:	$
SUB-TOTAL:	$
PROMOTION CODE :	#
TOTAL:	$