AQUANET.NET
FAX/MAIL ORDER FORM

QTY PART NUMBER DESCRIPTION PRICE EXTENDED
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                                                                                                                  Subtotal $__________

                                                      NC Residents Add 7.75 % Tax (Subtotal X 1.0775)
             $__________

                                                                              Orders Less Than $50.00 Add $7.95             $__________

                                                                                                                    Total $__________











BILLING INFORMATION SHIP TO (IF DIFFERENT)
Name Name
Company Company
Address Address
City City
State Zip State Zip
Email Phone Fax
VISA - MC - DISC CC# CSC#(*) Exp. Date
How did you hear about us?
* The CSC number is the last three or four digit number printed on the back where you sign your card.

Please mail to:
Aquanet.net
417 Caratoke Hwy, Unit C
Moyock, NC 27958

OR please fax to:

252-232-2102