3 State Pier Road	New London, CT	06320-5817
(860) 443-8499	Toll Free: (888) 813-8214	Fax: (860) 442-8699

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Product Code	Quantity	Product Description	Unit Price	Extended Cost
All goods are shipped FOB destination by ground service within the 48 contiguous states. Express delivery service surcharges and/or shipping charges will be added for express service or delivery to other destinations. Payment Attached     Credit Account ID#: __________________________			Subtotal
			Other Charges
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Credit Card:     Visa     Master Card
	Card Number:	____________ - ____________ - ____________ - ____________
	Expiration Date:	_____________________________________________________
	Name on Card:	_____________________________________________________
	Cardholder's Zip Code:	_____________________________________________________
	Authorized Signature:	_____________________________________________________

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