Chipman Dental Products - Fax Order Form

Printable Fax Order Form

Instructions:

Simply print this page from your web browser, fill out the information and
fax it to one of the following numbers: (610) 258-5009 or 1-800-814-7537.
Your order will be processed as soon as the fax is received.

Quantity:

4 Unit Dispenser Rack            Cost $49.95        Qty:______
5 Unit Dispenser Rack            Cost $59.95        Qty:______

(Plus $6 Postage per unit - all units shipped Priority Mail)


Customer Info: (Type/Print)

*Name:______________________________________________________________

*Address:___________________________________________________________

*Address2:__________________________________________________________

*City:________________________    *State:______    *Zip:____________

*Phone:_______________________    Email:____________________________



*Credit Card (check one):   Mastercard_____  Visa_____   AmericanExpress_____

*Credit Card Number:________________________________________________

*Expiration Date:____________________

*Security Code:________ (MC/Visa: 3 digit code on back of card)
                        (AmericanExpress: 4 digit code on front of card)

*Name as it appears on Credit Card:_________________________________




Comments:___________________________________________________________

____________________________________________________________________

____________________________________________________________________

*These fields are REQUIRED for proper processing of orders.