ADAPT Fax or Mail Order Form
Complete the information below and then print the form out. Mail or fax (540-622-2634) to ADAPT for immediate processing. To order by phone call 1-800-243-2665.
BILL TO:
Date
Name
Attn:
Title
Address
City
State
ZIP/Postal Code
Phone
E-Mail
Fax
SHIP TO:
Additional Comments/Delivery Instructions
Please select the desired payment method.
COD Please call for exact price
CHECK Payment must be received before equipment is shipped
CREDIT CARD
CARD#
EXP#
CARD HOLDERS NAME#
SIGNATURE#
NOTICE: Purchase Orders accepted upon approval of ADAPT Inc. Please call ADAPT's Customer Service for details at 1-800-243-2665
MAIL:
ADAPT Inc. Attn: Order Processing 888 Shenandoah Shores Rd Front Royal VA 22630
