Order Form for Sterilizers or Sterilizer parts.



 
 
 
 

Your last name
Your first name
Company if applicable
Type of Practice (choose one)
Address
City
State
Zip
Phone #
Fax #
Email 
 
 
 
 

 
Part #
Quantity
Description
Cost
 Sub total
Freight for North America 

check this box if it is priority overnight (parts $25., sterilizers ($135.)
 

or check this box if it is regular ground  (parts $12., sterilizers $95.) 

or this box if you want this to be shipped freight collect

* International (parts $65., sterilizers $245.). Customer to incurr custom & local duties.

   Freight

Total cost

 
 
 
MC  Visa  Amex  Discover 

  card #Expiration date/






You may also wire the money to

N. Fork Bank ABA 021407912 acct# 6124005502.

If that is what you choose to do, email this form the day you wire the money to us.