Fax / Mail Order Form
(Print this form, fill it out, and fax it to (413) 803 - 4318.)

Or mail to:

Connect On-Line Services, PO Box 766, Green Bay, WI 54305-0766

Note: We will e-mail you to to confirm your order notify you of any Shipping Costs based on the shipping method you choose below.

quantity:
quantity:
quantity:
quantity:
quantity:
quantity:

WI Residents Add 5% Sales Tax

  

Shipping

  

Total

  

Contact Information:
Name (as shown on credit card):  
E-Mail Address:  

Billing Information:
First Name:   Last Name:  
Address:   
 
City, State (or Province), Zip:  
Country:  

____US First Class
__US Priority Mail 
___ Check here to ship to Billing Address above or fill out the following:
Shipping Information:
First Name:   Last Name:  
Address:  
 
City, State (or Province), Zip:  
Country:  

Payment Method:  __ VISA     __ MasterCard     __Amex

Credit Card # and Expiration Date: