Model Innovations, LLC Product Order Form

Please print this form, and then fill in all information below.

Please send this form and payment to:

	Model Innovations, LLC
	P.O. Box 2122
	Salem, CT, 06420


Make checks payable to Model Innovations, LLC. 

Thank you for your business!



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				     Date:______/_____, 20_____


Name ______________________________________________________________


Address ___________________________________________________________


City _____________________________  State _______  ZIP ____________

U.S. Orders Only Please


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Enter the quantity of each item purchased.


Quantity    	Item Description	Cost Each        Shipping (each)
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  ____		1 pair: Eyeglass Wings with     $6.50	     $1.95    
                 Clear Pyramex ZTek
                 safety glasses.

  ____		1 pair: Eyeglass Wings with	$6.50	     $1.95
                 Tinted Pyramex ZTek
                 safety glasses.
                 
  ____		Speicial Purchase - 10 pair: 
                Eyeglass Wings with	  	$65.00	     FREE    
                 Clear Pyramex ZTek
                 safety glasses.

  ____		Speicial Purchase - 10 pair:
                Eyeglass Wings with      	$65.00	     FREE
                 Tinted Pyramex ZTek
                 safety glasses.                 

(CT residents add 6% sales tax)    TAX   $_________________  



                                   TOTAL: $_________________

Check No.(if paying by check) ______________________________________
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