ORDER FORM

ORDER FORM
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Ship to:

Company
Address
City
Province
Postal Code
Phone #
Fax #:

Terms:	Account COD Credit Card
Name of Cardholder
Card Number:
Card Expiry Date:	Month: Year:

Qty.	Part #	Description	Price Each
			Cdn$
			Cdn$
			Cdn$
			Cdn$
			Cdn$
			Cdn$
			Cdn$
			Cdn$

If you have any questions or comments, please feel free to contact us at 1-800-828-1496.

To place your order, please print this form and send to Fax: 905-683-7067

Mail: Heat Seal Equipment
530 Westney Road South, Unit #1
Ajax, Ontario, Canada
L1S 6W2