Print this form on your printer and fax along with both (2) sides of your credit card.
Please write as clearly as possible.
MicroDAQ.com FAX #: 603-746-5384
877-275-9606 or
603-746-5524
P.O. Box 439
Contoocook, New Hampshire 03229 USA
| SHIP TO: | BILL TO: | |
| addr: | addr: | |
| addr: | addr: | |
| city, state,zip | city, state,zip | |
| ATTN: | ATTN: | |
| PHONE: | PHONE: | |
| FAX: | FAX: | |
| E-MAIL: |
QTY |
ITEM # | DESCRIPTION | PRICE | EXT |
| TOTAL $ |
All amounts and funds are in US Dollars
Credit Card Information [ ] Visa [ ] MasterCard [ ] American Express |
| Card No.: Exp Date: |
| CCV (3 or 4 Digits on back of credit card): |
| Name as it appears on credit card: |
| Zip Code of credit card billing address: Signature: |
| SHIPPING : Within the continental United States our standard method of shipping is Fed Ex 2 Day delivery. |
| [ ] Ship Fed Ex 2-Day (U.S. orders only) [ ] Ship Fed Ex Ground (U.S. orders only, 3-6 business days based on your proximity to the state of New Hampshire) [ ] Ship Fed Ex Standard Overnight (U.S. orders only, by 3 p.m. next business day) [ ] Ship Fed Ex International Priority (typically 2-4 day delivery) [ ] Ship Fed Ex International Economy (typically 4-6 day delivery) [ ] Use my Fed Ex Account # ___________________ |
| NOTES: |