FAX OR MAIL ORDER FORM - Canada Only  
To make an order, please fill out and print the form below.
A customer service representative will contact you when your order ships.
Applicable tax(es) apply to all sales within Canada. If exempt for any reason, please call one of our customer care representatives for further assistance.
Product Code Product Name/Description Price Quantity
ITEM 1   
ITEM 2   
ITEM 3   
ITEM 4   
ITEM 5   
ITEM 6   
ITEM 7   
ITEM 8   
ITEM 9   
ITEM 10 
Personal Information
Your Name: Daytime Phone:*
Company Name: Evening Phone:*
Email Address: Fax:*
(*please include area code)
Billing Information: Shipping Information: (if different than billing address)
Address:
Address 2:
City:
Province:
Country: Postal Code:   
Address:
Address 2:
City:
Province:
Country: Postal Code:   
Method of Shipping:
Canada Post
Priority Courier
Xpresspost
Expedited Parcel
Regular Parcel 		Dicom (Ontario & Quebec Only)
Ground
Payment Information
Credit Card: VISA   MasterCard
Credit Card Number: CCID:  what's this? Expiry Date:
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