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Text File  |  1992-07-18  |  2KB  |  62 lines
  1.  
  2.  
  3.  
  4.                            ORDER Form  Fax or Mail
  5.  
  6.  
  7.    From: ________________________________________  ___________________
  8.            Name                                       Title
  9.  
  10.          _____________________________________________________________
  11.            Company
  12.  
  13.          _____________________________________________________________
  14.            Address
  15.  
  16.          _____________________________________   _____   _____________
  17.            City                                  State   Zip
  18.  
  19.          Phone (    )       -              (    )       -          fax
  20.                 ----   ----   --------      ----   ----   --------
  21.  
  22.  
  23.    To:
  24.    Order Dept.
  25.    Infinity Imaging Products
  26.    2000 Corporate Ridge #900
  27.    McLean, VA 22102
  28.    (703) 866-4189     __________________ fax
  29.  
  30.  
  31.  
  32.     Products Ordered
  33.  
  34.     Qty    Product                            Price       Amount
  35.  
  36.     ___    ________________________________   $_____     $_______
  37.  
  38.     ___    ________________________________   $_____     $_______
  39.  
  40.     ___    __________________________ $____   $_______   $_______
  41.  
  42.     ___    __________________________ $____   $_______   $_______
  43.  
  44.     ___    __________________________ $____   $_______   $_______
  45.  
  46.                                            Subtotal      $_______
  47.  
  48.                                   5% Tax if VA Address   $_______
  49.  
  50.                                            Shipping         $3.00
  51.  
  52.                                            Total PAID    $_______
  53.  
  54.  
  55.      Paid by  [ ] Check  [ ] Credit Card: [ ] MC  [ ] Visa  [ ] Discover
  56.               [ ] Other "
  57.  
  58.      Credit Card # ______________________________ Exp Date:______________
  59.  
  60.      Signature:________________________________
  61.  
  62.