| Affordable Health & Safety | |||||||||
| Product Order Form | |||||||||
| Customer Name: | Date: | ||||||||
| Phone: | Fax: | Email: | |||||||
| Shipping Address: | |||||||||
| Item # | Item Name | Qty. | Unit Price | Total | |||||
| Credit Card Information: (Visa/MC/AMEX/Discover, Only) | Sub Total: | ||||||||
| Name On CC: | Shipping & Handling | ||||||||
| CC Number: | Tax: CA Residents add 7.75% AZ add 7.95% | ||||||||
| Expiration Date: | Total: | ||||||||
| Shipping price | Amount of order | ||||||||
| $9.50 | $0.01 to $49.99 | ||||||||
| $14.50 | $50.00 to $99.99 | ||||||||
| $20.50 | $100.00 to $249.99 | ||||||||
| $37.50 | $250.00 to $699.99 | ||||||||
| $50.00 | $700.00 to $1,499.99 | ||||||||
| Free shipping | $1,500.00 and UP | ||||||||
| Please mail this form to | Or fax to 586-261-5111 | ||||||||
| Affordable Health & Safety, INC. | |||||||||
| P.O. Box 1623 | |||||||||
| Troy, MI 48099-1623 | |||||||||