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:

*Credit Card Type (Circle One):

• Visa
  
  
• Mastercard

*Credit Card Number:

__________-__________-__________-__________

*Expiration Date: _____/_____

Pricing: (Includes domestic shipping)

(1) for $9.75

(2) for $9.00 ea.

(3) for $8.75 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