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Order online at www.pssl.com Call Toll-Free: 1-800-268-5520 International Tel: 1-714-891-5914 Fax Toll-Free: 1-888-777-5329 International Fax: 1-714-891-6375
10743 Walker St. Cypress, CA 90630 USA
Please fill out all of the information below
ITEM Number
Product Name
Quantity
PRICE
TOTAL PRICE PRICE X QUANTITY
Sales Person Who Assisted You:____________________
Shipping Address Name: ____________________________________ Address: __________________________________ City: ________________ State: ____ Zip: _______ Daytime Phone: (
) _______________________
Cardholders Address (If different from above) Name: ___________________________________ Address: _________________________________ City: ________________ State: ____ Zip: _______ SALES TAX: Daytime Phone: (
) _______________________
E-mail Address*: ___________________________ *Your email address is used for order related purposes only. Our privacy policy guarantees that your information will be kept confidential, and we will not share, rent or sell your email address to other companies.
CA residents add 8.75% sales tax SHIPPING & HANDLING: Please call for rates on shipping & handling. Total Amount Enclosed: Make check/money order payable to PSSL.
Payment type: Visa / MasterCard / American Express / Discover Check/Money Order / Western Union / Financing Your card number (all digits please) ____ ____ ____ ____ - ____ ____ ____ ____ - ____ ____ ____ ____ - ____ ____ ____ ____ Your credit card will be charged only for merchandise shipped including applicable shipping and handling fees
____ ____ - ____ ____ Expiration Date Month/Year
*Prices are subject to change or correction without notice.
Print Name: ____________________________________________________ Signature: _______________________________________ Date:_____________
