Date: ________________
FAX to 416 255 4617 or mail to A-1 Electronic Parts at 196 North Queen St., Toronto ON, Canada M9C 4Y1
NAME:_____________________________ADDRESS:___________________________________
CITY:________________STATE_____________COUNTRY:_______________
POSTAL/ZIP___________PHONE:_________ E-MAIL:
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UPS ACCOUNT#:
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Orders over 2 lb, please call or email for shipping quote.
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| This is to certify that I am over the age of 16 and wish to purchase the products you have advertised. I hereby authorize A-1 Electronic Parts to debit my credit card for the amount of this order. Signature:__________________________________ | ||||
| Card # EXP. DATE | Shipping: | |||
| Signature__________________________ | Total: $ | |||