Print This Form and Mail to:

InterMark America Corporation
6947 Coal Creek Parkway SE #142
Newcastle, WA 98059

Note: If paying by check, you must allow time for the check to clear first. Using a money order allows you to receive your order much faster!

SHIP TO:

Name:_______________________________________________________
Address:_____________________________________________________
City:________________________________________________________
State:______________________ Zip:______________________________

Credit Card Billing Address (only if using a credit card)

Name:_______________________________________________________
Address:_____________________________________________________
City:________________________________________________________
State:______________________ Zip:______________________________

Credit Card Information:

Credit Card Number: ______________________________ Exp: ___________________
Name On Card: _________________________________________________________

Products You Would Like To Order:

Product Name:___________________________ Qty:_______ Price:_____ Total:_______
Product Name:___________________________ Qty:_______ Price:_____ Total:_______
Product Name:___________________________ Qty:_______ Price:_____ Total:_______
Product Name:___________________________ Qty:_______ Price:_____ Total:_______
Product Name:___________________________ Qty:_______ Price:_____ Total:_______
Tax (8.8% - Pay this ONLY if you live in the state of Washington)...........Tax: _______
Shipping & Handling: ............................................................................:________
Order Total.........................................................................................:________

Shipping & Handing charges:
-Unless you request otherwise, our "default shipping" is U.S. Mail, First Class.
Typical shipping time (not guaranteed) is 3-5 days.