Accessory Order Form

Date:________________

Billing Address: Shipping Address:

Same as Billing

Name:__________________________________________________ Name:__________________________________________________

Retail Store:_____________________________________________ Retail Store:_____________________________________________

Address:________________________________________________ Address:________________________________________________

City:___________________________________________________ City:___________________________________________________

State:____________ Zip:___________________________________ State:____________ Zip:___________________________________

Phone Number:__________________________________________ Phone Number:__________________________________________

Credit Card Information:

Method of Payment: VISA MASTERCARD AMERICAN EXPRESS

Name as it appears on card:____________________________________________________________________

Card Number:________________________________________________________Expires:________________ CVV Code_____________

Shipping Method:
Ground (1-5 days) 3 Day Select 2nd Day Air Next Day Air
*Shipping and Handling: Varies by address, weight of shipment and selected shipping method. Shipping prices range from $15-100.

Order Information:
QTY SKU DESCRIPTION ITEM PRICE TOTAL

TOTAL*
Email or fax this completed form to: E: orders@ergomotion.us -or- F: 805-979-9399
(excludes shipping)

Thank you for your order.

Ergomotion Inc. | ph 1-888-550-3746 | fx 805-979-9399 | www.ergomotion.us