|
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): |
(
)
|
| METHOD
OF PAYMENT: |
| |
Visa |
|
Mastercard |
|
|
| Card
Number: |
|
Expiry
Date: ______ /______
|
| Card
Holder Name: |
|
Signature: |
|
| BASE
PRICE: |
$ |
| OPTIONS:
|
$ |
| SUB-TOTAL:
|
$ |
| FREIGHT:
|
$ |
| G.S.T./H.S.T
(Canada Only).: |
$ |
| P.S.T.
(Ontario only): |
$ |
|
TOTAL:
|
$ |
|
