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ORDER FORMORDER NUMBER:_________________________ ACCOUNT NUMBER:__________________________ORDERED _________________________________________________DATE:_____________________2007/08 2nd EditionFOR OFFICE USEBILLING INFORMATIONFIRST NAME MIDDLE INITIAL LAST NAME_________________________________________________________________________________________________________ADDRESS_________________________________________________________________________________________________________CITY STATE ZIP CODE_________________________________________________________________________________________________________E-MAIL DAYTIME TELEPHONE #_________________________________________________________________________________________________________O Check here if your address has changed since your last order.SHIPPING INFORMATIONPlease complete the following, if order is to be shipped to different address:FIRST NAME MIDDLE INITIAL LAST NAME_________________________________________________________________________________________________________ADDRESS (No PO Boxes)_________________________________________________________________________________________________________CITY STATE ZIP CODE_________________________________________________________________________________________________________E-MAIL DAYTIME TELEPHONE #_________________________________________________________________________________________________________QTY ITEM NO. NAME OF PRODUCT EACH TOTALSometimes we may be out of stock, please check if you wouldlike us to:O Hold for BO; ship order complete.O Ship in-stock items now; ship BO when possible.O Ship in-stock items now; cancel BO.SHIPPING & HANDLINGADDITIONAL SHIPPING & HANDLING - As listed per itemNEW YORK RESIDENTS: PleaseAdd Applicable Tax on Taxable ItemsTOTAL AMOUNTM I N I M U M O R D E R $ 1 0 . 0 0PAYMENT INFORMATIONYou can charge my order to my:O DiscoverO Master CardO VisaO American ExpressACCOUNT # _________-_________-_________-_________EXPIRATION DATE _____/_____/_____x_______________________________________AUTHORIZED SIGNATUREDATE _____/_____/_____ PHONE #_______________ORDER IS VALID ONLY WITH AUTHORIZEDSIGNATURE AND PHONE NUMBERIMPORTANT: If you are claiming tax exemption, pleaseprovide a copy of your Exemption Form or Resale Certificate.US CONTINENTAL GROUNDSHIPPING & HANDLING CHARGESIf your order totals$10-24.99...add $ 5.85$25-49.99..........$ 6.65$50-99.99..........$ 8.70$100-199.99......$ 11.85$200-299.99......$ 13.25$300-499.99......$13.95$500-999.99......$17.95$1000-2000.......$19.95$2001+..add $10.00 foreach additional $1000Additional charges indicated when applicableShipping charges are not refundable. Additional shipping charges onitems where indicated. Shipping to Alaska, Hawaii, Puerto Rico, V.Islands & international ship to addresses require additional chargesthat will be added to your invoice.42 Executive Blvd.Farmingdale, NY 11735-0813To Order: 1-<strong>800</strong>-<strong>522</strong>-<strong>6294</strong>For Info: 1-631-752-0521 TTY: 1-631-752-0738Fax: 1-631-752-0689 Email: sales@maxiaids.comT H A N K Y O U F O R Y O U R O R D E R
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