Fax/Mail Order Form
Please print and use this form for FAX and Mail orders.
Customer Information:
| Name: |
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| Practice/Business: |
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| Address 1: |
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| Address 2: |
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| City: |
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| State/Region: |
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| Zip/Postal Code: |
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| Country: |
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| Phone #: |
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| FAX #: |
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| eMail: |
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Products:
| Product |
Quantity |
Price |
Extended |
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| Subtotal: |
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| UT State Tax* (Utah residents only) |
Rate: |
6.00% |
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| Shipping: Ground (one item): $8.95, For faster shipping please call 877-963-2633 |
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| TOTAL: |
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* To calculate tax, multiply the Subtotal amount by .06
Payment:
Check/Money Order Enclosed (Mail Orders)
Purchase Order #: (Please enclose or fax for our records.)
Credit Card (circle one) Amex Discover MC Visa
Card #:
Exp. Date:
Name on Card:
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Comments & Questions:
FAX or Mail this Form
| FAX: |
(877) 272-0780
(toll-free) |
| Mail: |
InstaCode Sales
2314 West 8900 North
Dammeron Valley UT 84783 |
Thank you for your order!
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