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Print out This Page (cut and paste as a Word Document will probably be the easiest)

ORDERED FROM............................:
SOLAR-EZ, INC.

Mt. Pleasant, MI 48858

Print Out This Page, Complete it and fax it to: 989-249-6613.

SOLD / SHIP TO:

NAME: ________________________________________________

ADDRESS: _____________________________________________

ADDRESS: _____________________________________________

CITY: _________________________________________________

STATE: _____________ ZIP CODE: _________________

QUANTITY...........DESCRIPTION.......................EACH............ENTRIES

__________ ...........SOLAR SADDLE ..........................$119.85......... __________

__________ .........SHIPPING & HANDLING................$9.95........ __________

...................................Michigan Orders 6%.Sales Tax (if applicable) __________

..............................................................................................TOTAL __________

TYPE OF PAYMENT: CREDIT CARD, CHECK, MONEY ORDER

CREDIT CARD: VISA, MASTERCARD, DISCOVER, (PLEASE CIRCLE)

CREDIT CARD #: ______________________________________

SIGNATURE NUMBER #_________(Last three numbers in signature box on back of card)

EXPIRATION DATE: ____________________

SIGNATURE (REQUIRED AS PRINTED ON CARD):________________________________________

PHONE NUMBER: ________________________________(MUST BE INCLUDED)

E-MAIL ADDRESS _______________________ (Please Include to verify messages)

(stop cut and paste first line above, you may need to change margins to fit on one page)

THANK YOU FOR YOUR ORDER

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