Pitrone & Associates Fax Order Form

Pitrone & Associates Office Order Form

Billing Information

Name:__________________________________

Company:_______________________________

Address:________________________________

City:________________________State:______

Country:___________ZipCode:_____________

Phone Number:__________________________

Fax Number:____________________________

E-Mail:________________________________

Shipping Information

Name:__________________________________

Company:_______________________________

Address:________________________________

City:________________________State:______

Country:___________ZipCode:_____________

Phone Number:__________________________

Fax Number:____________________________

E-Mail:________________________________

Product____________________________Quantity_______Price Each________ Total_________

Shipping________ PA State (ONLY) 6% Sales Tax_______ Total_____________

Charge to my: [MasterCard]____[Visa]____[Discover-Novus]____[American Express]______

Cardholder Name:_________________________________________

Card Number:___________________________________________

Exp Date:_________________

Signature:_______________________________________Todays Date:_________________