To place an order using this form:
Print out this form, fill out the requested information, then
mail to 127 Lincoln Square, Urbana, IL 61801
or
fax to (217) 344-1557.
Call toll free (877) 388-8843 if you have questions.
Name (First):
Name (Last):
Street Address:
City:
State & Zip:
Daytime Phone:
FAX:
E-mail Address:
Check enclosed
Charge Card:
VISA
MasterCard
Discover
American Express
Card Number:
Signature:
To place an order for more than 3 items at a time, print and fill out additional order forms and fax or mail all pages at the same time.
Local delivery, UPS or overnight delivery are available.
Please indicate your shipping/delivery requirements for each item. We will calculate the shipping/delivery fees, as well as any sales tax, and provide this information on your confirmation.
Item#1:
Product Number / Name of Product
/
Price / Quantity
/
Overnight Delivery? (if available)
NO
YES
Gift Wrapping? ($3.00 charge)
NO
YES
If yes, name for gift card enclosure:
Shipping information if different from above:
Item#2:
Product Number / Name of Product
/
Price / Quantity
/
Overnight Delivery? (if available)
NO
YES
Gift Wrapping? ($3.00 charge)
NO
YES
If yes, name for gift card enclosure:
Shipping information if different from above:
Item#3:
Product Number / Name of Product
/
Price / Quantity
/
Overnight Delivery? (if available)
NO
YES
Gift Wrapping? ($3.00 charge)
NO
YES
If yes, name for gift card enclosure:
Shipping information if different from above:
