| Credit Card Billing
Address |
Shipping Address |
| Name: |
Name: |
| Organization: |
Organization: |
| Address
1: |
Address
1: |
| Address
2: |
Address
2: |
| City: |
City: |
| State
+ Zip: |
State
+ Zip: |
| Country: |
Country: |
| Phone: |
Phone: |
| Fax: |
Fax: |
| Email: |
Email: |
|
|
| PAYMENT
INFORMATION |
| _Visa
_Mastercard _ AMEX |
Expiration
Date: __________________ |
Card # ________________________________ |
Signature__________________________ |
|
| Item
Number |
Name |
Qty |
Unit
Cost |
Total |
| |
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|
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|
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| |
Subtotal |
|
| |
7%
NJ Sales Tax |
|
| Shipping
Method |
|
Shipping
Price |
|
| |
Total |
|
|
| Shipping
Option |
Price
(up to 3 items) |
Price
(each Add'l Item) |
| Refills
Only (1st Class) |
$
3.25 |
$
0.50 |
| 3
Business Day Delivery |
$
8.95 |
$
0.95 |
| 2
Business DayDelivery |
$16.95 |
$
0.95 |
| Next
Business Day Delivery |
$29.95 |
$
2.95 |
| International:
Express Mail |
$39.95 |
$
4.95 |
| Canada
USPS First Class: |
$14.95 |
$
3.00 |
| Canada
USPS Express: |
$29.95 |
$
3.00 |
|
