P.O. Box 1, Muncy, PA 17756
FAX: 570-546-2249
PHONE: 570-546-5923 or 570-546-5924
I have read the conditions of purchase listed elsewhere in this Catalog.
I also understand these items to be of a hazardous nature if misused
and to be used only under Adult Supervision. I am of Legal Age for use
and possession of this product in the State of my residence.
I hereby understand and agree to the above and accept full responsibility
Your Signature_______________________________________________________
SHIP TO (Please Print):
NAME __________________________________________ DATE ________________
BUSINESS ADDRESS WILL SAVE RESIDENTIAL FEE CHARGED BY CARRIER
ADDRESS______________________________________________________________
CITY _____________________________________ STATE ____ ZIP ___________
Payment: $__________ Total of Order: $________________
Payment Method (circle one): MONEY ORDER M/C VISA
A fireworks permit (circle one) IS IS NOT required in my State.
First Order? YES___ NO ___
MAKE ALL MONEY ORDERS PAYABLE TO: A & W SALES CO.
REMEMBER:
MINIMUM MAIL ORDER IS $100.00 | All orders must be submitted with
MINIMUM PICK-UP ORDER IS $50.00 | PAYMENT IN FULL, INCLUDING FREIGHT.
NO EXCEPTIONS | (Over-payment of freight will
| be refunded.)
Thank you for your co-operation.
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TO BE FILLED OUT BY THOSE WHO CHARGE
WITH EITHER "MASTERCARD" OR "VISA":
(Circle One) MASTERCARD VISA
Expiration Date on Card _______________________________
Telephone: (Area Code) _________/______________________
NAME___________________________________________________
BILLING ADDRESS________________________________________
CITY _______________________STATE _______ZIP_____________
ACC0UNT
NUMBER:|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
________________________________________________________
Signature of Card Holder
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| Stock | | Price Per Description | | |
| No. | Quantity | Each, Gross, Doz., Etc. | Price | Extension |
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|# | | |$ |$ |
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Sub Total of Order - - - - - - - - - - - - -|$ |
____________
Pennsylvania Residents Add 6% Sales Tax Here |$ |
____________
Shipping Charges |$ |
____________
GRAND TOTAL |$ |
____________
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Print or copy additional forms if needed.
A new order form will be shipped with your order.
Pennsylvania Residents MUST Add 6% sales Tax.
