Printable Order Form

From:_____________________________________________(Name)

Email address___________________________________________

Phone number________________________Fax_________________

To: Nevada Technical Associates, Inc.

----Fax No. 1-702-558-7672

----P.O. Box 90748

----Henderson, Nevada 89009

I would like to purchase the following items:

Name of Item Quantity Unit Cost Total Cost

_______________________________________________________________

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Shipping cost....................................._____________

Payment Method (circle one)>>> Check Purchase order Credit card

If paying by credit card, please list:

a. Card type_____________________________________

b. Card number___________________________________

c. Name on card__________________________________

d. Expiration date (month/day/year/)______________

e. Signature of card holder approving purchase_________________________

Ship the items ordered to the following address:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Provide billing address if different from above:

___________________________________________________________________

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