Authorized Reseller

Printable Order Form

CLICK NOW TO PRINT AN EMPTY FORM OR ENTER DATA BELOW THEN PRINT

Please enclose this form with your check, money order made payable to:

TRIBUTE MARKETING

MAIL or FAX TO:

Tribute Marketing/PFM Dept.

PO Box 802

Attleboro, MA 02703 USA

Tel: 508-455-4646

Fax:508-455-4647

Billing Information: Name:

Street Address (same as credit card billing address)

Street

City State Zip

Shipping within USA Only. International Shipping of a medical device is restricted.

Qty.	Peak Flow Meter #PF100	$55.95
Qty.	COMBO Meter/Software #PF100-SWCOMBO	$ 79.95
Qty.	Analyzer Software/Cable #PF100S	$ 26.95

		Subtotal
	Mass. Residents Only Sales Tax	5%
	Shipping: USPS Priority Mail w/Delivery Confirmation	$5.95
		TOTAL

Method of Payment:

Personal Check Enclosed Money Order or Bank Check Enclosed

Credit Card (information below)

16 Digit Number

3 Digit Authorization code on back of card. (signature panel, on right)

Expiration Date: Month Year

Shipping Address if different than billing address above: Shipping within USA Only