Wedge-Ease™ Ergonomic Support Products: Order Form

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Order Form

Please complete this form and press the button at the bottom of the page to print. You may then fax or mail your order by using the info on your right. Once we receive it, we'll contact you immediately to complete your order!

Place your order by:
PH: (310) 614-3933
FAX: (949) 515-3569
or
MAIL:
1835 Newport Blvd.
Suite A109-247
Costa Mesa, CA 92627

Contact Sheet / Order Form

P.O. No.

Date:

Name:

Title:

Company:

Department:

Shipping Street Address:

City: State: ZIP:

Billing Street Address:

City: State: ZIP:

Telephone:

Fax:

E-Mail Address:

Product Description	Item Number	Unit Price	Quantity	Price
3 inch wedge, vinyl	W-3	$22.99
2 inch wedge, vinyl	W-2	$21.99
1 inch regular stacker, vinyl	S-Reg	$21.99
Start-Up Kit: Not sure what to order? Try our Sample Kit, includes one of each size for a quantity of 4. A $86.96 value for $78.27	Start-Up Kit	$78.27
Mini Stacker	S-Min	$19.99

Plus sales tax, postage and handling

Method of Payment: Credit Card Check/Money Order