ORDER FORM

Please provide the following contact information:

Name

Title

Organization

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

Home Phone

FAX

E-mail

Please provide the following product information:

Product Name

Product #

Color

Ceiling Height

Length from ceiling to lowest part of fixture

Type

Miscellaneous Staining Crating

Add Any Notes

Please provide the following ordering information:
If you are not comfortable entering your credit card information you may call us at: (203) 847-3231
and leave the Credit Card information blank.

BILLING

Credit Card #

Expire Date /

Name on Card

SHIPPING

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

Product Name
Product #
Color
Ceiling Height
Length from ceiling to lowest part of fixture
Type
Miscellaneous	Staining Crating
Add Any Notes

	SHIPPING
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country