print order form, fill out, and fax to 954-788-8893 |
Items in italics are optional - All others are required. Please print really big, dark, and clear. (or type).
Name as shown on credit card |
Email Address (for order confirmation) |
Daytime Phone # | Fax # |
Billing Address |
Address 1 |
Address 2 |
City | State | Zip |
Shipping Address (if different from billing) |
Name | |
Address 1 |
Address 2 |
City | State | Zip |
Credit Card Information ( x check one) |
Visa ( ) | MasterCard ( ) | American Express ( ) |
Card # | Expiration Date |
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Order Form Page 2 |
Name |
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Item # |
Quantity |
Unit Price |
Extension |
CR1 Sit-down Use |
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$99.95 |
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CR3 Sit or Stand |
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$119.95 |
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CR5 Heavy Duty |
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$199.95 |
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Order total |
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Shipping - Add 8% of Order total - $7.00 minimum chg. |
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Sub-total |
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Florida Residents add 6% Sales Tax |
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Total to be charged to credit card |
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or - Call us at 1.877.INSTAND (877.467.8263) |