Printable Order Form

From:__________________________________________________(Name)

Email address___________________________________________

Phone number________________________Fax_________________

To: Nevada Technical Associates, Inc.

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

----P.O. Box 93355

----Las Vegas, NV 89193

I would like to purchase the following items:

Name of Item Quantity Unit Cost Total Cost

_______________________________________________________________

_______________________________________________________________

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:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________