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Microscopes America, Inc.

Please Fax to: 1-770-889-6253

 

Please Place This Order For:

My Schools Name / Institution: _____________________________________________________________________________________

My name Is: ___________________________________________________________________________________________________

My title Is: ____________________________________________________________________

My Department Is: ______________________________________________________________

I would Like This Order To Be Billed To: ______________________________________________

This Order Will Be Shipped To: _____________________________________________________

Street Address: ____________________________________________________________________ City: __________________

State:____________ Zip code: ___________________

Telephone#: __________________________ Fax Number: ___________________________ E-mail: ________________________

PAYMENT WILL BE MADE BY PURCHASE ORDER: # _________________________

PAYMENT WILL BE MADE BY CREDIT OR DEBIT CARD:

Visa MasterCard Discover

Card Number: # __________________________________________ Expires: _________________
Please Note: (This option is available to you if you prefer not to send your credit card information over the internet)

My Signature Authorizing This Order__________________________________________ (Signature Is Mandatory)

Quantity Ordered	Order Number	Brief Item Description	Unit Price	Total

Subtotal: _____________________________

(In GA., and not tax exempt?) add 5% Tax (If Applicable):_____________________________

Microscopes America Pays for Shipping: NO CHARGE

Grand Total: _________________________