PRINT Name:_________________________________________________________________________________
Firm/Org/Agency/Inst:_________________________________________________________________________
Address:_____________________________________________________________________________________
City:____________________________________ State:___________________ Zip:___________
Telephone: (_________)
_______________________________
E-Mail:__________________________
QUANTITY................ITEM...........................................................SUBTOTAL...............TOTAL
_______ __________________________________________________ $________________ $_________________
_______ __________________________________________________ $________________ $_________________
_______ __________________________________________________
$________________ $_________________
_______ __________________________________________________ $________________
$_________________
_______ __________________________________________________ $________________ $_________________
_______ __________________________________________________ $________________ $_________________
Shipping via
USPS Priority Mail or Best Way.
Subtotal of Order:$________________________
**CHECKS/MONEY ORDERS Must Be Made Payable To: USCCCN INT'L, INC./AMERICAN FOCUS):
NJ(Only) Purchasers Must Add 6% NJ Sales Tax: $________________ Exempt#:______________________
Total
Including Sales Tax (NJ Only):$____________________________
Total of Check/Money Order Enclosed:$___________________________
****CREDIT CARD ORDERS:
Sub-Total of Ordered Items:$_______________________________
NJ (Only) Purchasers
Must Add 6% NJS Tax $________________ Exempt#__________________________
Total Including Tax (NJ Only):$__________________________
Credit Card: ___Visa __Master Card __AMEX __Discover ....................Expiration Date:________/_______
Credit
Card Number:____________________________________________________________________________
Code on Reverse of Credit Card:____________________________________________________
Name on Card:_________________________________________________________________________________
Address of Card Holder:______________________________________________________________________________
Signature:_____________________________________________________________________________________
