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Credit Card Information Ship To Information
   

Name as on CC ___________________

Name __________________________

Street __________________________

Street __________________________

City ______________ St ___ Zip_____

City ______________ St ___ Zip_____

Phone (____)____________________

Phone (____)____________________

CC No.__________________________ Expiration Date ____/____ CVC Code ______

Authorizing Signature __________________________

 
 

Width

x

Length

=

Total Sq In

x

Per Sq In

=

Each Cover

  

Cover 1

_____

x

_____

=

_______

x

$0.14

=

$________.___

  

Cover 2

_____

x

_____

=

_______

x

$0.14

=

$________.___

  

Cover 3

_____

x

_____

=

_______

x

$0.14

=

$________.___

  

Cover 4

_____

x

_____

=

_______

x

$0.14

=

$________.___

  

Cover 5

_____

x

_____

=

_______

x

$0.14

=

$________.___

  

Cover 6

_____

x

_____

=

_______

x

$0.14

=

$________.___

  
 

Locks

        

______

x

$20.00

=

$________.___

  

Tabs

        

______

x

$5.00

=

$________.___

  

Reinforcing Angle*

        

______

x

$25.00

=

$________.___

  

* One reinforcing angle is needed for each 12" beyond 36" Width
* One reinforcing angle is needed for each 12" beyond 24" Length

Sub-total

 

 

 

 

 

 

 

 

$________.___

  

Sales tax (if in IL)

    

Sub-total

$______

x

7%

=

$________.___

  

Total Purchase

 

 

 

 

 

 

 

 

$________.___

  

 Notes and Comments: