Antona Corporation HTML Order Form    

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

*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

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