Bandages - Online.com                                    
PRODUCT ORDER FORM                             Home

Customer Name:
Phone:
Billing Address (same as the CC):
Shipping Address:
Date:        /       /

Item Number
Item Name
Quantity
Unit Price
Total
         
         
         
         
         
         
         
         
         
         

Credit Card Information (VISA / MC / AMEX / Discover, only)
Name on CC :
CC Number :
Expiration Date :
Authorized By*  
(*signature)
SubTotal:
  
Shipping & Handling:
  
Tax:
(CA residents add 8.25%)
  
Total:
  

           SHIPPING INFO:
Your Total is:                                 Shipping Price: Your Total is:                                        Shipping Price:
$0.01 to $9.99                             $6.50 $200.00 to $399.99                            $28.50
$10.00 to $49.99                          $8.50 $400.00 to $699.99                            $28.50
$50.00 to $99.99                          $12.50 $700.00 to $1000.00                           $28.50
$100.00 to $199.99                       $17.50 $1000.00 +                                        FREE


Bandages-Online      Suite: 108A - 217      300 Carlsbad Village Dr.        Carlsbad, CA 92008
Email: info@bandages-online.com  - Toll Free: 1-800-480-1277   FAX: 1-760-436-2358