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Fax or Post this Form to: Fax : (937) 773-6772 DJ Aerotech 719 Fisk St. Piqua, OH 45356 USA Shipping Address Name:___________________________________ Address:_________________________________ Address:_________________________________ City, State:____________________________ Zipcode, Country:______________________ Billing Address Name:___________________________________ Address:_________________________________ Address:_________________________________ City, State:____________________________ Zipcode, Country:______________________ Home Phone:____________________________ Email:__________________________________ Visa:_____ Mastercard:_____ AMEX:_____ Card Number:___________________________ Expiration date:__________________________ or make checks payable (in US Funds) to DJ Aerotech We accept personal checks or cashier checks in US Funds ONLY please. Quantity Item Price Each Price Total _______ ______________________________________________________ _________ _________ _______ ______________________________________________________ _________ _________ _______ ______________________________________________________ _________ _________ _______ ______________________________________________________ _________ _________ _______ ______________________________________________________ _________ _________ _______ ______________________________________________________ _________ _________ _______ ______________________________________________________ _________ _________ _______ ______________________________________________________ _________ _________ _______ ______________________________________________________ _________ _________ _______ ______________________________________________________ _________ _________ Sub-Total _________ Ohio Residents please add Sales Tax (6.25%) _________ Esitimated Shipping _________ Please, US Funds Only Total _________