Please fill out the following form

AND

Mail to:

Voltage Converter Transformers

619 Acadia Tr.

Roselle,

ILL.- 60172

 

OR

Fax To:

Voltage Converter Transformers

Fax 1(847)-595-9900

 

 

I , ___________________, Authorize Voltage Converter Transformers to charge my credit card for the purchase of the item(s) listed below.

Name on Credit Card:

LAST:_____________________FIRST:____________________MIDDLE:_______________

e-mail:___________________________________

TELEPHONE NUMBER(S):

WORK (____)______________ Cell (____)______________

HOME (____)______________ Fax (____)______________

CARD TYPE:
                VISA    MASTERCARD    DISCOVER    AMERICAN  EXPRESS

                CARD#:______________________________________ EXP DATE________________

BILLING ADDRESS:

__________________________________________________________________________________

SHIPPING ADDRESS:

__________________________________________________________________________________

Phone number for the card issuing bank (Usually on back of card): _____________________________

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Quantity

DESCRIPTION

UNIT PRICE

TOTAL

_____________

_____________________________

_________________

____________________

_____________

_____________________________

_________________

____________________

_____________

_____________________________

_________________

____________________

_____________

_____________________________

_________________

____________________

_____________

_____________________________

_________________

____________________

 

SHIPPING

CHARGES

____________________

 

IL Residents add 7.75% tax

____________________

 

 

GRAND TOTAL 

FOR THIS ORDER

$______________ USD

TERMS AND CONDITIONS:

We always carry top quality products which have been approved by our technical staff. This lets us sell our products with total confidence. However, as with all machine made products some repair work might become necessary and the following terms apply:

Sign here to confirm order ____________________Date ________

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