Pumpboxtm.net

Pumpboxtm Faxable Order Form

                        

Use this form to place an order by mail or fax.  Fill it in on your computer and the form will calculate your total.  Then print it and send it to us:

Pumpbox tm Inc.
670 NE 15th Place
Boynton Beach, FL 33435, USA

FAX: (866) 651-4476

  
Name   (As shown on credit card)
Address  
(Address)  
City   State/Prov.
Zip/code   Country
Telephone   Fax
Email  
Payment        Cashiers Check
Card Number  
Expiration  
Signature   <<sign after printing

Units

Product

Unit Price

Extended

Pumpbox 410 1050.00
Clear Replacement Lid    
Locking Lid Screws    
Subtotal
Sales Tax (FL residents**) 6.25%
Total

Use your browser's Print command (on the File menu) and send us the form!