Order Form

Actionmatic Ltd.

P.O. Box 326,
Chatham, Ontario
Canada
N7M 5K4

Phone: (519) 351-2181
Toll Free in North America: 1-800-265-8363 (VEND)
Fax: (519) 351-7304

After filling out this form please click the submit button at the end of this form. Please click the submit button ONLY ONCE, it may take a few minutes to process.  You will receive confirmation that your order has been sent successfully.

Mandatory Fields Indicated with *

Business Name:	*
Personal Name:	*
Your email address	*
Your telephone number	*
Your fax number

Billing address
Your street address	*
Your city	*
Your ZIP/Postal code	*
Your state/province	*
Your country
Shipping address Same as billing address

Your street address
Your city
Your ZIP/Postal code
Your state/province
Your country

Order
Quantity (pcs) Item Description	Method of Payment: Visa Mastercard Bank Transfer Certified Cheque Shipping Instructions: UPS Post Office Transport

Notes:
Verification code:
Enter verification code:	*