Crutch Tote Mail Order Form

Print and Mail to: Crutch Tote™, 100 E.  Bellevue Pl. Suite 4E, Chicago, IL 60611
 
PLEASE PRINT

ORDERED BY

SHIP TO (If Different)

Name

   

Address

   

 City/State

 

Zip:

 

Zip:

 Day Phone

   

Alt. Phone

   

FAX

   

E-mail

   

Shipping Address is a __ Residence    __Business

QTY

Description

UNIT PRICE

TOTAL

 

 Crutch Tote™ Crutch Bag(s)

 17.95

 
 

Sub Total

 

Shipping

 $6.95

IL State Tax

 

Amt. Due

 

Please be sure to enclose check or money order, payable to Crutch Tote™

TERMS: Net cash with order. Orders will be shipped upon receipt of payment.