Visual Labels Order Form
Please use the Print button in your browser to print this form. Fill out the printed form, and then send or fax it with your payment to:		BMT Micro PO Box 15016 Wilmington NC 28408 Fax: 910-792-1889

Name (Please Print)
Address
City			State / Province
Zip / Postal Code			Country
Phone #
Fax #
E-Mail Address
Alternate E-Mail

Item Description	Price Each	Quantity	Price
Visual Labels	$19.95 (US)
North Carolina Residents please add 6.5% sales tax
Total Amount Enclosed

Payment Method (circle):  CASH   /   CHECK   /   MONEY ORDER   /                                        VISA   /   MC   /   DISCOVER   /   AMERICAN EXPRESS

** Please make check or money order payable to "BMT Micro" ** All checks or money orders in US Funds only

Please add the following information for credit card orders: Card# _________________________________    Exp. Date: ____ / ____ EXACT Name on Card: _________________________________________ Signature ____________________________________________________