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Print this form & MAIL or FAX to:
RehabMart.com
1367 Sydney's Pass
Watkinsville, GA 30677 (USA)
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U.S. Toll Free Fax: (888) 507-7326
International Fax: (678) 254-1791
Toll Free Phone: (800) 827-8283
Email: order@rehabmart.com
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Credit
Card Billing Address |
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* You must fill-in this section completely * |
Email |
________________________________ |
Full name |
________________________________ |
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________________________________ |
St Address |
________________________________ |
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________________________________ |
City |
________________________________ |
State |
________Zip Code_________________ |
Country |
________________________________ |
Day phone |
________________________________ |
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Date |
________________________________ |
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Ship
To Address |
 (Check here if same as
billing information)
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Full name |
_______________________________ |
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_______________________________ |
Street Address |
_______________________________ |
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No P.O. Box |
_______________________________ |
City |
_______________________________ |
State |
________Zip Code________________ |
Country |
_______________________________ |
Day phone |
_______________________________ |
Other phone |
_______________________________ |
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Shipping
Preference: (ground only) |
UPS/ USPO Ground 3-5 days
2-day Next day (s&h quote will be sent to email address provided) |
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Payment
Information |
Visa
MC
Amex Discover
Mail-in
Check Wire
Transfer |
| Credit Card Holder
Signature: ___________________________ I authorize my card to be charged for the total amount listed below |
Credit Card #
_______________________________________________________________________ Exp
(mm/yy)________ /________ Security Code (back of card) ______
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Exact Name on Credit Card / Check
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_______________________________________________ |
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(Check) Bank Name:
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_______________________________________________ |
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(Check) Routing # (first 9 or 10 digits
on check)
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_______________________________________________ |
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(Check) Acct #(last
11 or 12 digits on check)
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_______________________________________________ |
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| Item # |
Item Name |
Quantity |
Price/each |
Total |
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GA residents
add 7% sales tax
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** US Customers Add $9.00
S&H fee - shipping cost determined by product being ordered. (AK, HI, PR & International
Customers: additional S&H charges apply: call or
email for quote quotes@rehabmart.com
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TOTAL |
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