Send Old Cartridges  Check or Money Order and this form to:

Cartridge Cahuna

P.O. Box 7212.

Romeoville, IL 60446

Info@cartridgecahuna.com  Fax 000.000.0000

Saving You up to 70%

The following number must appear on all related correspondence, shipping papers, and invoices:

P.O. NUMBER:      

Ship To:

            Name:     

            Check No.     

            Address:     

            City:                              State:

            ZIP     

P.o. Date

requisitioner

Ship via

f.o.b. point

terms

Check or Money Ord.

qty

Order #

Equip. Make/Model    -    Description

unit price

total

$  

SUBTOTAL

$

SALES TAX

Add $5.00 (US) SHIPPING & HANDLING (for US orders less than $20.00)Outside US e-mail or call

SAVE $3.00 (US)per cartridge ordered with the return of old cartridge

-     

TOTAL

$

1.   Special Instructions: _____________________________________________________

2.   List any problems or symptoms: ____________________________________________

3.        Contact:  _____________________  Phone:  ________________________

                                                                   Fax:       ___________________

Bill Total to: N/A – Under Construction

(Billed on product ship date)

Master Card  _xx___      Visa  _xx___

  __xx____ __xx____ __xx____ ___xx___

              (16 Digit Account No.)

  __xx____  (4 Digit Expiration Date)

  __________xx________________

           (Name as Appears on Card)

  __________xx________________

                 (Authorized Signature)

----  For Internal Use Only  ----

Date Received: ___________                                                                                                                                            Date Shipped: ___________     

                                                                                                                                                                                            Form Printed:  06/18/2001