To: ZipNut Technology, LLC
Date: ________________
Please send:
________ SCBA compressor connections part # HTN85DZ CGA347 @ $199.00 each plus shipping.
(Quantity)
________ 2.5 inch fire hose adapters part # ZNFH25 @ $159.00 each plus shipping.
(Quantity)
Company: _____________________________________________________________________
Shipping address: _______________________________________________________________
Billing address: _________________________________________________________________
E-mail: ___________________________________
Telephone: _______________________________ FAX ___________________________
Name & Title: ___________________________________________________________________
Authorized signature _____________________________________________________________
Credit card: VISA ______ MasterCard ______ (Check one)
Name on card: _________________________________________________________________
Number: ______________________________________________________________________
Expiration date: _____________________
OR
Purchase Order: Invoice in accordance with attached Purchase Order.
OR
Telephone: Call for additional ordering information.
PAYMENT METHOD
ZipNut Technology, LLC
7700 Leesburg Pike Suite 301N
Falls Church, VA 22043
www.zipnut.com
Toll free: 888-894-7688
FAX 703-734-9620
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Copyright ZipNut Technology, LLC, 2010
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