RESCUE 51 ORDER FORM           Fax to: 610-266-6150
Mail Orders To:
Rescue51
P.O. Box 72
Catasauqua, PA 18032

Please Print Neatly

Name: ________________________________

Address: _______________________________            

City/State/Zip: ________________________________

Phone: ________________________     Email Address: ________________________


Shipping Address (only if different from above)

   __________________________________

   __________________________________

   __________________________________



Add additional shipping for lights (see light pages)

Shipping & Handling Charges: Payment Method:

$0-$25.00 -$5.00                 __ Check/Money Order    __ Visa

$25.01-$50.00 -$6.00           __ Mastercard      __ Am. Express

$50.01-$100.00 -$8.00           Card Number:

$100.01-$150.00 -$10.00           _______________________________

$150.00-more -Free                  Expiration Date: ____/____

Rescue Bucks Code ________           Signature: ______________________(not valid unless signed)

 

To view all our products, check us out on line at www.rescue51.com Offers 24 hours a day, 7 days a week and secure server.