COMPUMATIC TIME RECORDERS, INC. 800-925-4506 828 BRUCE DRIVE 516-486-3538 EAST MEADOW, NY 11554 FAX: 516-781-0990 Order form, please print and submit with payment Date ____________ Last Name: ____________________ First Name: ____________________ Phone Number: (______) -______-________ ext (______) Fax Number: (______) -______-________ E-Mail: ________________________________________________________________ Billing Address: ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ Shipping Address: (use company name if applicable, indicate if SAME as billing address) ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ Item Name: ________________________________________________________ ________________________________________________________ Item Description (if applicable): _______________________________________________ ______________________________________________________________________ ______________________________________________________________________ Quantity: _______ Price (sub-total): $________.____ Shipping: $________.____ Total: $________.____ CHECK OR MONEY ORDER ACCEPTED PLEASE MAKE FUNDS PAYABLE TO COMPUMATIC TIME RECORDERS, INC. IF USING A CREDIT CARD: TYPE (circle one) VISA/MASTERCARD/DISCOVER/AMERICAN EXPRESS CARD NUMBER ___________________________________ EXP DATE ____________ Please make sure the billing address above matches the credit card billing address SIGNATURE _______________________________________________________________________ COMMENTS, SPECIAL INSTRUCTIONS, or PRINT PREFERENCE (if applicable): __________________________________________________________________________________ __________________________________________________________________________________