Brodak Order Form

Please print this out and fax or mail the fully completed form to:

Name: _______________________ Company name : _______________________________

Address : ______________________ City, (Province/State) : _______________________

Country : _______________ Zip/Postal Code :______________ Date: ____________________

Phone : _________________ (and/or) Fax ___________________

Merchandise total : ______________________

Less ( PAMPA discount -10% ) :_______________________

Shipping Charge : ______________________

Canadian Res. add 7% GST : _____________

Total : ______________________

Method of Payment : __ Visa , __ MasterCard, __ Money Order, __ Cheque, ___ On approved account

If paid by Visa or Master Card provide:

Name of Card Holder : ____________________________ Signature : __________________________

Expiry Date : ________________ Visa / MasterCard # : __________________________________________

PAMPA Status from latest membership manual : ______

Shipping method : ___ air mail, ___ surface mail, ___ UPS, __________ other. (Please check one.) Shipping charges shall be added to Merchandise total. Order confirmation and invoice shall be provided by this office.

Credit card purchases shall be charged at time of shipping.
Personal cheques must be certified, if not the merchandise shall be held till the cheque clears before shipping.