AQUANET.NET, INC
FAX/MAIL ORDER FORM

QTY PART NUMBER DESCRIPTION PRICE EXTENDED
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Subtotal $__________
VA Residents Add 5 % Tax $__________
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, Inc.
4661 Curtiss Drive
Virginia Beach, VA 23455

OR please fax to:

757.464.3979