Mail-In/Fax Order Form

     Print this form out when you have entered the necessary information and send it to the address at the bottom or fax it to us at 330-533-6353.


       FULL NAME:  _______________________________________________                

   
TELEPHONE NUMBER: _______________________________________

   

      SHIPPING ADDRESS:  ________________________________________        

EMAIL ADDRESS:  ___________________________________________       
    
   

YOUR ORDER:                 
 
  

 

    MARK QUANTITY NEXT TO EACH ITEM:


                  .5” PAIR OF SHOE INSERTS - ($10.50)     ______________
              1.00” PAIR OF SHOE INSERTS - ($11.95)   ______________
              1.25” PAIR OF SHOE INSERTS - ($13.75)   ______________
              1.50” PAIR OF SHOE INSERTS - ($15.45)   ______________
              1.75” PAIR OF SHOE INSERTS - ($17.95)   ______________
              2.00” PAIR OF SHOE INSERTS - ($19.50)   ______________
              2.25” PAIR OF SHOE INSERTS - ($21.50)   ______________
              2.50” PAIR OF SHOE INSERTS - ($23.95)   ______________
              3.00" PAIR OF SHOE INSERTS - ($29.95)   ______________

If ordering (4) of each size deduct 18%, if ordering (8) of each size deduct 36% from
the individual pricing.


      SAMPLE PACK #1 1”, 1.5”, 2” PAIRS --------------------($29.95)  ____________

      SAMPLE PACK #2 1”, 1.5”, 2”, 2.5” PAIRS --------------($48.50)   ____________
SAMPLE PACK #3  1/2", 1 1/4", 1 3/4" PAIRS ------------($29.50)  ____________
SAMPLE PACK #4  1/2", 1 1/4", 1 3/4" and 2 1/4" PAIRS- ($42.75) ____________
SAMPLE PACK #5  2 1/4" and 2 1/2" PAIRS-------------- ($32.50) ____________
SAMPLE PACK #6  2 1/2" and 3" PAIRS-------------------($41.95) ____________
ULTIMATE SAMPLE PACK--------------------------------($89.50)  ____________
 
                                         
SHIPPING AND HANDLING:


       - REGULAR FIRST CLASS MAIL ------------------------  (ADD  $6.95)    ________

       - PRIORITY MAIL ------------------------------------------(ADD $11.95)  ________

      - INTERNATIONAL SHIPPING (REST OF WORLD) ----- (ADD $12.95)  ________

AMOUNT OF US DOLLARS ENCLOSED
---------------- $___________________

CHECK OR MONEY ORDER TOTAL AMOUNT
---------$____________________

VISA/MASTERCARD/DISCOVER:

ACCOUNT NUMBER
  ________________________________________________

THREE DIGIT CODE 
____________

EXPIRATION DATE 
____________

      NAME AND ADDRESS ON ACCOUNT IF DIFFERENT FROM ADDRESS ABOVE


      FULL NAME:                ______________________________________________________

      BILLING ADDRESS:    ______________________________________________________

 

 

      SEND PAYMENT TO:

 

                                                  Canfield Plastics

                                                 10670 Lisbon Road

                                                 Canfield, OH 44406

 

     

                               FAX TO:   330-533-6353