| Ship to |
| Name:___________________________________ Title:____________________________________ Department:______________________________ Institution:________________________________ Street:___________________________________ |
City:______________________________________ State:_____________ ZIP:____________________ Country:___________________________________ Phone:________________ Fax:________________ Email:_____________________________________ |
| Product Name | Price | Quantity | Total |
| Seeing
and Hearing Speech CD-ROM for Windows® XP/Vista |
US$85.00 | ||
| Total Merchandise $ | |||
| Shipping and Handling* + | |||
| MA residents add 6.25% sales tax / CA residents add 7.25% sales tax + | |||
| TOTAL $ | |||
|
*All orders will have shipping costs calculated based on weight. Please contact Sensimetrics directly for Express Shipping information. |
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| Credit Card Information |
| |
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| Card #__________________________________________
Expiration Date____________ Signature________________________________________ For Visa, MasterCard, Amex or Discover orders, mail this form to the address below or fax it to (781)399-0853.
For Phone orders, please call (781) 399-0858
Ext. 235. |
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