Order Form

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Quanity Pricing:
1 to 10 $19.95ea - Plus $3.95ea for Tax & Shipping
11 to 50 $17.95ea - Plus $3.95ea for Tax & Shipping
51 Plus $15.95ea - Plus $3.95ea for Tax & Shipping

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*Qty
*Payment Type
*CC Number
*Exp. Date
*3 Digit ID
*CC Number
*Exp. Date
*4 Digit ID
Mail Checks to: A Ray Dalton Inc.
 

777 Lena Drive
Aurora, OH 44202
Bill to:    * Name
Company
*Address
Address
*City
*State
*ZIP
Country
Ship to:  * Name
Company
*Address
Address
*City
*State
*ZIP
Country
  *Ship to: Is the same as Bill to:
* Phone
Fax
* E-mail
Shipping Instructions :
777 Lena Drive - Aurora, OH 44202
Phone: (330)562-9900 - Fax: (330)562-9901 - Email: rdalton@new-vista.com