Phone: (916) 691-9100 or Toll Free (877) 691-9150 Fax: Complete form, print and fax to: (916) 691-9190 Mail: Complete form, print and mail to: 5050 Laguna Blvd. Suite 112-560, Elk Grove, CA 95758

Qty   Qty   Qty     Box of 1000=$320.00 Box of 500=$180.00 Box of 250=$100.00  Shipping and handling for first box $7.00, add $2.00 for each additional box   California add 7.75% tax   Total

Shipping Address

Billing Address

   Check if same as shipping address

Name Company Address City   State Zip Country Phone Fax E-mail

Name Company Address City   State Zip Country Phone Fax E-mail

Payment Method

P.O. (Attached)  Check  Money Order

P.O. Number

Additional Instructions: