QTY
Model No.
Brief Description
Unit price
Amount
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
SALES ____________
Shipping&Handling* __$40__
TOTAL ____________
* Rent it912s only $69 for 2 weeks, S&H is non-refundable
Charge to:___ VISA/MC ___ AMEX ___ Discover Amount: USD____________
Contact Email:_________________________________________________
Cardholder's name:______________________________________________________
Billing addr:_____________________________________________________________
Card No. : |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
Expiration Date: |___|___|___|___|
Cardholder's Signature:___________________________________________________
Phone Number: ________________________ Fax number: ______________________
Ship to: ____________________________________________
______________________________________________
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