Masune Printable Order Form (Only for Order by Fax, or by Mail)
(This form is for customers to print out, and order by mail or by fax. It is not for orders through Web. Click for updatable form.)
Masune First Aid & Safety 500 FILLMORE AVE. TONAWANDA, NY 14150 USA Print Fax: 1-800-222-1934 Phone: 1-800-831-0894 (24 Hours/Day, 7 days/week)
	SHIP TO:		Phone No.:	_______________________________
Co. Name:	_______________________________		Purchase Order No.:	_______________________________
Attn:	_______________________________		Authorized By:	_______________________________
Address:	_______________________________		Title or Dept.:	_______________________________
City:	_______________________________		Date:	_______________________________
State:	______________ Zip:___________		Customer No:	_______________________________
	BILL TO: (If different from SHIP TO)		Bill Our Account
Co. Name:	_______________________________		Charge My Credit Card
Attn:	_______________________________		Credit Card No.:	_______ _______ _______ _______
Address:	_______________________________		Expiration Date:	___/___
City:	_______________________________		Signature:	_______________________________
State:	______________ Zip:___________		Name of Cardholder:	_______________________________
Circle One Type: Visa MasterCardAmerican ExpressDiscoverSmartPayTM

Item No.	Qty.	Item Description	Size	Color	Unit Cost	Total
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Shipping & Handling
(AL,AR,AZ,CA,CO,CT,DE,DC,FL,GA,IL,IA,IN,KS,KY,LA,MA,MD,MI,MN,MS,MO,NE,NM,NJ,NY,NC, ND,NV,OK,OH,OR,PA,RI,SC,SD,TN,TX,UT,VA,WA,WV,WI Customers Only)Sales Tax
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