tankless water heaters

5812 Antigua Dr
Port Orange, Florida 32127
Phone: 386-767-9887
Fax: 386-767-7983
     

Print this form, keep it handy while you browse our products. Complete it then mail or Fax it to us. Once we recieve your order form by fax or mail, your order will be processed and shipped usually within 24 hours via UPS Ground or US Priority mail. Special expedited services or shipments outside the continental U.S.A. will incur additional charges, please call for pricing.  .   Print Form    Close Window

Please print clearly. * Required fields.

 HEATER VERIFICATION

Heater Type:

 _________________________________

Model #:

 _________________________________

* Gas Type:

      Natural Gas     Propane    

   

 PERSONAL INFORMATION
* Name: _________________________________
 Company: _________________________________
* Address: _________________________________
* City: _____________________
* State: __________ * Zip: __________
* Phone: _________________ Fax: _________________
* Email: _________________________________

    

 ORDER INFORMATION

P.O. # _______________________
Part # Description Quantity Total
       
       
       
       

Shipping & Handling Charges Continental US Only

Sub Total: 

 $_________________

SHIPPING AND HANDLING

Order Value

 $1-50  $51-$100  $101-$190 

$191 ->
Standard $10.00 $11.00 $12.00

CALL
Overnight $34.00 $38.00 $40.00

CALL
2nd Day $18.00 $20.00 $22.00

CALL
3 Day $15.00 $17.00 $19.00

CALL

Florida Residents 
add 6.5% Sales Tax: 
$_________________

Shipping: 

 $_________________

Total: 

 $_________________

 SHIPPING ADDRESS

Use Address Above
Address: _________________________________      Business Residence
City: _____________________
State: __________

Zip:

 __________

   

 PAYMENT INFORMATION
* Payment Type:   Check Credit Card   Money Order
* Credit Card Type: ____________________

* Credit Card Number:

 ________________________________

* Expiration Date:

 _____/_____
* Signature: _____________________________________