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 and mail this completed form along with payment to Sultantronics P.O. Box 1707 Sultan, WA. 98294.

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) $6.30

                    GRAND TOTAL_______________