SupportsUSA

ABrace.Com Mail-In or Fax-In Order Form
Complete and Send to:
SupportsUSA
14275 Midway Rd. Suite 155
Addison, TX 75001		 Order By Fax - 24 hours/day:
Fax 1-800-432-6516
Billing Information

Name:

Address:

City/State/Zip:

City/Providence/Postal Code:

Country:

Area Code:               Phone:

E-Mail Address (Optional):

 

 Shipping Information (if different than billing)

Name:

Address:

City/State/Zip:

City/Providence/Postal Code:

Country:

 
Description Item # Size Color Quantity Price Each Total Price
             
             
             
             
             
  Total Price
Of Items		    
Shipping Charges    
Total     
Method of Payment:
__ Check or Money Order (US Dollars)
      (Payable to SupportsUSA) Must be mailed
__ VISA   __  MasterCard  
__  American Express

Credit Card Number :  _______________________________________

Expiration  _____/_____  (Month/Year)

Signature:		 Shipping Charges:

$5.95 on Ground Shipments
$20.00 For 2nd Day Air Shipments
$30.00 For Overnight Shipments

Sorry, we only ship inside the US on Mail-In Orders

ABrace.Com