USED MONITOR SHOP
Print out this form, then FAX it to 1-514-221-2385 or call
1-514-999-0712
Personal Information
Name: __________________________________________________________________
Company: __________________________________________________________________
Address: __________________________________________________________________
__________________________________________________________________
City: ___________________________ State: _____ Zip Code: _________
Daytime Phone: _____________________ Work Phone: _____________________
E-mail address: ____________________________________
Please send me the following products:
DESCRIPTION PRICE QTY SUBTOTAL
_______________________________________ _____ ___ ________
_______________________________________ _____ ___ ________
_______________________________________ _____ ___ ________
_______________________________________ _____ ___ ________
_______________________________________ _____ ___ ________
Shipping & Handling +________
TOTAL ________
Credit Card Information
Credit card (VISA, MASTERCARD)
Card Number: ___________________________________ Exp. Date: __________
Name on card: ___________________________________
Signature: ______________________________________ Date: ___________
Billing address:___________________________________________________
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