 |
Print this form and MAIL or FAX to:
RehabMart.com
150 Sagewood Dr.
Winterville, GA 30683 |
Fx: (603) 843-2144
Ph: (800)
827-8283
Email: info@rehabmart.com |
|
Credit
Card Billing Address |
|
* You must fill-in this section completely * |
Email |
________________________________ |
Full name |
________________________________ |
|
|
________________________________ |
St Address |
________________________________ |
| |
________________________________ |
City |
________________________________ |
State |
________Zip Code_________________ |
Country |
________________________________ |
Day phone |
________________________________ |
|
Date |
________________________________ |
|
Ship
To Address |
 (Check here if same as
billing information)
|
Full name |
_______________________________ |
| |
_______________________________ |
Street Address |
_______________________________ |
|
No P.O. Box |
_______________________________ |
City |
_______________________________ |
State |
________Zip Code________________ |
Country |
_______________________________ |
Day phone |
_______________________________ |
Other phone |
_______________________________ |
|
|
|
Shipping
Preference: (ground only) |
UPS/ USPO Ground 3-5 days
2-day ($25-$50 surcharge)
Next day ($30-$75 surcharge- depending
on weight) |
|
Payment
Information |
Visa
MC
Amex Discover
Mail-in
Check Wire
Transfer |
| Customer
Signature: _____________________________ add
$20 fee for Int'l wire transfers |
Credit Card #
_______________________________________________ Exp
(mm/yy)______ /______
Security Code (back of card) ___________
|
|
Exact Name on Credit Card / Check
|
_______________________________________________ |
|
(Check) Bank Name:
|
_______________________________________________ |
|
(Check) Routing # (first 9 or 10 digits
on check)
|
_______________________________________________ |
|
(Check) Acct #(last
11 or 12 digits on check)
|
_______________________________________________ |
|
|
| Item # |
Item Name |
Quantity |
Price/each |
Total |
| |
|
|
|
|
| |
|
|
|
|
| |
|
|
|
|
| |
|
|
|
|
|
GA residents
add 7% sales tax
|
|
|
** US Customers Add $9.00 shipping &
handling. (AK, HI, PR & International
Customers: additional S&H charges apply: call or
email for quote info@rehabmart.com
) |
9.00
|
TOTAL |
|
|