CycleStat^® DC Counter

FAX credit card order to 1-360-681-8540 or mail with payment to ESC Products Corp., P.O. Box 520, Carlsborg, WA, USA 98324

Name:
Address:
City:	State/Province:
Zip/Postal Code:	Country:
Telephone Number:
Qty _____  CycleStat® MC-1-12V at $79.95/ea,   total  $____________ Qty _____  CycleStat®t MC-1-24V at $84.95/ea,   total  $____________ Qty _____  CycleStat® MC-1R-12V at $99.95/ea,   total  $____________ Qty _____  CycleStat® MC-1R-24V at $104.95/ea,   total  $____________
Add Priority Shipping if desired (see How to Order):   $__________
Washington residents add state sales tax at 8.3%:  $__________
Total for order:   $______________
Method of Payment:	Credit Card Number & Expiration Date:
Name of cardholder (please print)                                 Signature of cardholder:

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