Bill To:

*First Name:____________________________

*Last Name:____________________________

*Address:______________________________

*City:____________ *State:_____ *Zip:________

Ship To: (Only use if different than Bill To)

First Name:___________________________

Last Name:___________________________

Address:_____________________________

City:_____________State:_____ Zip:_______

Payment Information: (Circle One)

• Check
• Visa
• Mastercard
• American Express
• Discover

*Credit Card Number:

_________________________________________

*Expiration Date: _____/_____

Pricing: (Includes USA domestic shipping)

(1) for $16.45

(2) for $15.50 ea.

(3) for $15.00 ea.

**For quantities of 4 or more, or international
orders, please send an email to the address listed
on our web site for a special quotation.

*Quantity Ordered: _______

Order Placement:

To fill this order, you may either mail or fax
this completed form to us.

Fax: (518) 273-0419

Mailing Address:

Industrial Tool & Die
14 Industrial Park Road
Troy, NY 12180
USA