SULTANTRONICS ORDER FORM

FOR BEVERAGE ANT. PORT SAVER

Print out this blank form and fill it out. You can pay by check or money order or charge it with Visa or Mastercard and mail this completed form along with payment to Sultantronics P.O. Box 1707 Sultan, WA. 98294 or (for charge card orders only) FAX the completed form to 360-793-9513.

Name_________________________________________________

Address_______________________________________________

City, State, Zip___________________________________________

Daytime Phone number___________________________________

(only used for emailing confirmation of order and date of shipping)

Email Address___________________________________________

MODEL(756, PRO or PRO2)                  QTY

___________________________________________________

___________________________________________________

___________________________________________________

                      TOTAL QTY_______________

TOTAL PRICE (TOTAL QTY x $30.00)______________

SALES TAX  8.5%(WA residents only)____________

SHIPPING/HANDLING (USA only ,up to 1 lb) $6.05

                    GRAND TOTAL_______________

Payment: ___Check/money order __VISA __Mastercard

Card Number______________________________________

Expiration date_____________________________________