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 261
	Bozrah, CT, 06334


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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  ____		Eyeglass Wings with	   $8.95	     $4.05    
                 Clear Pyramex ZTek
                 safety glasses.

  ____		Eyeglass Wings with	   $8.95	     $4.05
                 Tinted Pyramex ZTek
                 safety glasses.

(CT residents add 6% sales tax)


TOTAL: $_________________

Check No.(if paying by check) ______________________________________
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