Name:
Address:
CityStateZip
Country
Billing Address:
CityStateZip
E-Mail:
Voice Phone Home:
Voice Phone Work:
Fax Phone
Preferred Payment Method:
If paying by Credit Card, enter your number,
Expiration Date
Name as it appears on the card
Your card will be verified for approval and
a phone call made to you for your voice verification prior to our accepting
your credit card payment. Once approved and verified your purchase will
be shipped. This is for your protection as well as ours. Thank You.
Your Order
Item No.QuantityPriceTotal
Item No.QuantityPriceTotal
Item No.QuantityPriceTotal
Item No.QuantityPriceTotal
Item No.QuantityPriceTotal
Item No.QuantityPriceTotal
Item No.QuantityPriceTotal
Sub-Total
CT Residents add 6% Sales tax
Shipping and Handling Charges to be specified
when we call to verify the order
Total Due With Order
You can also order by Phone,
Fax or mail.
PHONE:
1.800.334.4625
FAX:
1.860.767.9121
MAIL: RefGear
37 Industrial Park Road
P.O. Box 236
Essex, CT 06426
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