DATE
FIRST NAME
LAST NAME
STATE
ZIP
PHONE #
( Required by UPS -
Format (####)###-#### )
# OF CLOCKS
INCLUDE BATTERIES ?
( 4 Duracell AA + 2
Duracell 9V $14.00
additional per set )
# OF CARRY CASES
( Case $25.00
when purchased
with LAX Clock ,
$29.50 purchased
alone.)
SHIPPING METHOD
(
UPS GROUND unless otherwise specified )
EMAIL ADDRESS
( Will receive
email from
UPS with Tracking #
)
PAYMENT TYPE
CC
$150.00
CHECK IN ADVANCE
$140.00
PO $155.00
Credit Card Type
School PO #
( Must FAX PO to
(631) 828-6695 )
Credit Card #
Card EXP Date
Card 3 Digit Security Code
Card Billing Address
Card
Billing Zip
