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Order Form - Fax to 212-941-1796

Customer Information - Circle if:     Business   or    Residence

Name:
Company Name:
Address:
City:	State:		Zip:
Phone:		Fax:
Email:

Shipping Address - Check if same as above_____  Circle if: Business or Residence

Name:
Shipping Address:
City:	State:		Zip:
Phone:		Fax:

Method of Payment
Please circle method of payment:
Check              Money Order          Credit Card (Visa and MasterCard only)
Please allow 10 business days for checks to clear.  Payment in full must be received prior to shipment in US dollars.  Make check payable to Ventilaire™ Industries Ltd.  Mail check or money orders to:Ventilaire™ Industries Ltd., PO Box692, New York, NY  10013
If ordering by credit card please fill in the following:

Name as it appears on credit card:

Account Number:_______-_______-_______-_______

Expiration Date:_______/_______

Type of Credit Card (circle one):              Visa                 MasterCard

Signature:___________________________________Date:_________________

©1999-2009 Ventilaire™ Industries Ltd.. All rights reserved PO Box 692, New York, NY 10013-0692 | | Fax: (212) 941-1796 | sales@Ventilaire.com Serving the industry since 1947