You may download this form to your own computer or print it directly from this site. EZ FLUSH ADAPTERS
Postal Order Form

Remit form and payment to:

DON COLLIER
39 E. Ledgendwood Road
North Stonington, CT 06359

Name:__________________________________ Date:_____________________

Company Name:______________________________________________________

Billing Address:_______________________________________________________

Sending Address (if different from above)_______________________________________________________________________

Please enclose $14.99 per adapter along with Shipping and Handling Fees (see S&H schedule below).
Make check or money order payable to;
EZ Flush Adapters

EZ Flush Adapters	Order Form
Quantity	#
Sub Total	Amt.
Shipping & Handling	Amt.
Total	$

Shipping and Handling Charges:
up to 4 adapters $4.95
For orders over 4, please E-Mail Customer Service for a price quote on S&H charges.