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SupportsUSA.com - Mail-In or Fax-In Order Form
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Complete and Send to: SupportsUSA 14275 Midway Rd, Ste 155 Addison, TX 75001 |
Order By Fax - 24
hours/day: |
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| Billing
Information
Name: Address: City/State/Zip: City/Providence/Postal Code: Country: Area Code: Phone: E-Mail Address (Optional):
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Shipping
Information (if different than billing)
Name: Address: City/State/Zip: City/Providence/Postal Code: Country:
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| Description | Item # | Size | Color | Quantity | Price Each | Total Price | |
| Total Price Of Items |
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| Shipping Charges | |||||||
| Total | |||||||
| Method of Payment: __ Check or Money Order (US Dollars) (Payable to SupportsUSA) Must be mailed __ VISA __ MasterCard __ American Express Credit Card Number : _______________________________________ Expiration _____/_____ (Month/Year) Signature: |
Shipping Charges:
Within Continental USA KneeBrace.Biz
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