This is not a secure page.  Fill out form online by typing into form.  Print form and then write credit card numbers on form after printing. Fax form to 845-297-9772 or send by mail.

 

Customer name *

Company name  

Shipping address *

City *    State *    Postal code *
Phone number *      email 
Payment method         Visa         MasterCard         Check
PRINT FORM, WRITE CARD NUMBER BELOW AND FAX TO  845-297-9772
Card number  ___________________________________________________________________
Expiration date  ___________________    Name on card *
Card holder address if different than ship address 
City     State     Postal code 

QTY

DESCRIPTION

UNIT COST

AMOUNT

    Item total

If blank we will calculate shipping

Shipping

           

Subtotal
 

New York State residents

NY State tax
  * DENOTES REQUIRED FIELDS   Total
  print form and fax to 845-297-9772