PRODUCT ORDER
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Customer Name:
Phone: Fax:
Shipping Address:
*
Billing Address:
*
Date:        /        /2003

 
Item Number
Item Name
Quantity
Unit Price
Total
         
         
         
         
         
         
         
         
         
         

Credit Card Information (VISA / MC / AMEX / Discover, only)
Name on CC :
CC Number :
Expiration Date :
Authorized By*  
(*signature)
SubTotal:
  
Shipping & Handling:
  
Tax: (CA residents add 8.25%)
  
Total:
  

               Shipping Info:              

                                   Your Total is:                       Shipping Price:

$0.01 to $9.99                                    $6.50 $200.00 to $399.99                                         $28.50
$10.00 to $49.99                                $8.50 $400.00 to $699.99                                         $28.50
$50.00 to $99.99                                $12.50 $700.00 to $999.00                                         $28.50
$100.00 to $199.99                             $17.50 $1000.00 +                                                      FREE
 

Emergency-Survival      Suite: 108A - 217      300 Carlsbad Village Dr.        Carlsbad, CA 92008
email: info@emergency-survival.com     -    Toll-Free: 1-800-480-1277        Fax: 1-760-720-6278