| Ordered by: | Ship to (if different): |
| Name: ______________________________ | Name: ______________________________ |
| Address: ____________________________ | Address: ____________________________ |
| ___________________________________ | ___________________________________ |
| City:______________________________ | City:______________________________ |
| State/Province:____________________ | State/Province:____________________ |
| Zip/Postal Code:___________________ | Zip/Postal Code:___________________ |
| Country:___________________________ | Country:___________________________ |
| Contact phone:__________________________ | Contact phone:__________________________ |
| Contact email:__________________________ | Contact email:__________________________ |
| Purchase order #:________________________ | Customer Ref #:__________________________ |
| Credit Card Information: | Credit Card #____________________________________________ |
|---|---|
| MC/Visa/AmEx (Circle one) | Security Code________ |
| Expiration Date:______/______ | Signature________________________________________________ |
| ANC-Num | Quantity | Description (if no ANC number) | Price Each | Total |
|---|---|---|---|---|
| Merchandise Total | ||||
| CA Sales Tax (8.25%)* | ||||
| Shipping** | ||||
| TOTAL DUE |
*Orders within California - or include California resale certificate
**Shipping will be calculated and added to total. We ship within
the USA by UPS ground, and internationally by DHL. Customer may specify
shipping method by using the space above. We can not bill to a customer account or any 3rd party.
For international orders, be aware that shipping varies from $45.00US to over $100.00US depending upon destination.
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Antona Corporation - 4187 Knobhill Dr., Sherman Oaks, CA. 91403-4647
Copyright © 1998-2007 Antona Corporation, L.A.,CA.,U.S.A.