ADCO Hearing Products, Inc.

This is not ORDER ONLINE You may print this ORDER FORM to place your order Please check ORDER INFORMATION for placing your order
ORDERED BY: *Note - UPS does not deliver to P.O. Box addresses*
Name:
Address:
City:	State or Province:
Zip Code:	Country:
Daytime Phone with Area Code:		Voice TTY
Evening Phone with Area Code:		Voice TTY
Fax with Area Code:	E-Mail:
SHIPPED TO: *Complete only if address is different than ORDERED BY shown above*
Name:
Address:
City:	State or Province:
Zip Code:	Country:
Daytime Phone with Area Code:		Voice TTY
Evening Phone with Area Code:		Voice TTY
PAYMENT BY:
- - - Expiration Date: Mo. Yr.
Type name exactly as it appears on credit card:

Qty

Item No.

Item Description

Color/Size

Price Each

Total Price

Subtotal

CO Residents - Add 7.85% Sales Tax

Shipping & Handling - See Chart Below

TOTAL

Shipping and handling costs for continental U.S. only,
Alaska, Hawaii and all others - please call for quote.