Print this out and send it in or go to our online
ordering section to order electronically.
SCROOGECLAMPTM
ORDER FORM
| Name: |
| Address 1: |
| Address 2: |
| City: |
| State:
Phone:( )
- |
| Zip: |
| Number of tools: |
Credit Card Type (circle one): _   |
| CardHolder's Name: |
| Credit Card Number:
Exp: / |
Shipping and Handling:
Please add $7.00 for the first tool and $5.00 for
each additional tool.
OH Residents please add correct sales tax.
MAIL TO: Pittsburgh Adjustable Brace
Company
Po box 464
Malvern, OH 44644
Phone: 1-330-224-4795
_________Tools @ $29.95 __________
Shipping and Handling __________
Sales Tax (OHIO
Residents Only)____________
Total Enclosed ____________________
Credit card or money order only - No C.O.D's
Please allow 1-3 weeks for Delivery
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