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Print this form and MAIL or FAX to:
5757 Whitmore Lake Rd / Brighton, MI / 48116
Fax: (810) 227-6201 Ph: (888) 322-7387
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* You must fill in all fields
| E-mail |
_____________________________ |
| Full Name |
_____________________________ |
| St Address |
_____________________________ |
| City |
_____________________________ |
| State Zip Code |
_____________________________ |
| Country |
_____________________________ |
| Day Phone |
_____________________________ | | |
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Check here if same as billing information
| Full Name |
_____________________________ |
| St Address |
_____________________________ |
| City |
_____________________________ |
| State Zip Code |
_____________________________ |
| Country |
_____________________________ |
| Day Phone |
_____________________________ |
| Other Phone |
_____________________________ |
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Credit Card Details
Credit Card # ____________________________________
Exp (mm/yy) ____________________________________
Exact Name on Credit Card ________________________
CVV Code on back of card: ________________________
Customer Signature ______________________________ | |
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Quantity |
Item Name |
Item# |
Price |
Total |
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| Product Sub Total |
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| Shipping |
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| Michigan Addresses add 6% Sales Tax |
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| Total |
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Print This Form
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