Where Did You Hear About Us?

BRUSHTECH INC.

ONLINE STORE

ORDER FORM

Where did you hear about us?

Email Address:

Date:

BILL TO:

Name

Address

City State Zip

Telephone Number:

SHIP TO: (IF DIFFERENT)

Name

Address

City State Zip

Quantity / Item # / Item Description / Price Each / Total
Merchandise Total
Shipping & Service (See Chart)
Subtotal
8% Sales Tax on NY State Deliveries
Total

Method of Payment Shipping & Handling Fees

Up to $24.99 / $6.95
Up to $44.99 / $8.95
$45.00 and More / FREE

  VISA

  MASTERCARD

  AMERICAN EXPRESS

  DISCOVER/ NOVUS

  POSTAL MONEY ORDER

  BANK MONEY ORDER

  CERTIFIED CHECK

PLEASE DO NOT SEND CASH OR PERSONAL CHECKS

Credit Card Number - - - Expiry Date

Authorized Signature

E-Mail, Mail Or Fax Your Orders To:

Brushtech Online Store

P.O. Box 1130 – 4 Matt Ave

Plattsburgh, NY, 12901

Tel: 518-563-2401

Fax: 518-563-0581

Email:

Please note: for the Online Store’s return policy, please view Returned Goods Form.