Mail Order Form
Please select this form with your mouse before printing- upon request
this form can be
e-mail to you if preferred, prices, descriptions, sizes and availability
subject to change
mail
ComNur.com , 518 Massasoit Rd., Worcester, MA 01604 USA
Subtotal
Massachusetts
only) 6.25%
Sales Tax Shipping
Total
MasterCard
Visa
Discover
American Express Expiration Date
List last three #'s from back of card for,Matercard,Visa &
Discover___________________ List last 4 #'s above card # for American Express Check Enclosed
Please note orders are not placed until checks clear We add $30.00 handling charge for returned checks Please keep a copy of this form for your records
Please provide the following Bill to
information:*(required)
First name*
Last name*
Street address*
Address (cont.)
City*
State/Province*
Zip/Postal code*
Country
if not USA
Work Phone
needed by UPS/FedEx or
Home Phone
UPS/FedEx
E-mail
Please
provide the following SHIP to information: Same as Billings
If different Ship to address is please list with any Additional Comments/Special Instructions
