Pin and Patch Factory Order Page

ORDER FORM

A.E.M. ENTERPRISES
P.O. BOX 146 Iselin, N.J. 08830
PHONE: (732) 602-2152 FAX: (732) 602-0529 . . . . . . . . . . . . . . . . .. . . . . .DATE:________________
WWW.PINANDPATCHFACTORY.COM

Page 1

SHIP TO:
Name:__________________________________________

*Address:_______________________________________

City:___________________________________________

State:_______________Zip Code:___________________

Telephone:______________________________________

E-Mail:_________________________________________

*Please use street address for shipping. No P.O. Boxes.

BILL TO:
Name:_____________________________________

Address:___________________________________

City_______________________________________

State:__________Zip Code:___________________

Telephone:_________________________________

FAX YOUR ORDER 24 Hours a Day-7 Days a Week

PHONE: 732-602-2152 FAX: 732-602-0529

QTY.

______

PRODUCT #

___________

PRODUCT DESCRIPTION

______________________________________________

_______________________________________________

______________________________________________

PRICE EACH

__________

TOTAL

__________

Page 2

METHOD OF PAYMENT:

Sub-Total

* NJ Tax 6 %

Shipping Charge

Total Order

__________

CARD NUMBER (ALL DIGITS PLEASE) . . . . . . . . . . . . . . . . EXPIRATION DATE:

._ _ _ _ . _ _ _ _ . _ _ _ _ . _ _ _ _ . . .. . .. _ _ /_ _

CARD HOLDERS NAME (PLEASE PRINT)_________________________________

CARD HOLDERS SIGNATURE__________________________________________

*SHIPPING CHARGES

$.01-$25.00 add $5.50
$25.01-$50.00 add $6.50
$50.01-$75.00 add $7.50
$75.01-$100.00 add $8.50
$100.01-$150.00 add $10.50
OVER $150.00 Call for Quote!