** - Headings with two "*" are for required information. Please print out, complete, and fax order form to: 1- 613 - 737 - 4860
** Shipping Address ( If you have a different Billing Address; please fill out the table at the end of this form. )
If you don’t have a different billing address and are only ordering a few items you will only have to print out and fax us the first page of this form.
** Name:.
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Company Name.
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** Address.
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** City and State (or Province) .
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** Zip Code / Postal Code.
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Contact Information:
** Phone
Number:		 . Alternate Phone Number: .
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E-mail Address: Recommended: This way we can send you shipping conformation. .
Payment Information: "Brouwer Manufacturing Ltd." is the name that will appear on your credit card statement.
** Type of Credit Card
(please circle 1 of 3):
Visa - MC - AmEx
 ** Card Number: .
** Expiry Date
(month / year ):
/
 ** Holder Name
(as it appears on card):		 .
Your Purchase order number; if applicable:.
.
 Shipping and Handling (see appropriate buy now web page):
** Speed ( please circle one of three ):
Fast - Regular - Slow
$C$
Shipping and Handling Cost:
.CnD
USD
$C$ - Circle the appropriate currency: USD for United States Dollar or CnD for Canadian Dollar.
What would you like us to ship?
** Quantity Item # Item Name Price Each $C$ Price Total
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Billing Address
Name:.
.
Company Name.
.
Address.
.
.
.
.
City and State (or Province) .
.
Zip Code / Postal Code.
.