Escan order form

Circle your choice of shipping method
Call 800-653-4252 or 951-270-1911 for shipping & handling cost

Purchase Order #_______________________ (upon credit approval)	Prepayment by Company Check	COD $7 fee	VISA	MasterCard	American Express
Discover	Bank Wire Transfer (call for bank info)	Western Union

Circle your choice of payment
NOTE 1: Credit cards are not accepted for the purchase of plastic card products.
NOTE 2: Purchase Orders must be faxed in to process order 951-270-0920

Credit Card Number
Cardholder's First & Last Name
Expiration Date (MM/YY)
Credit Card Billing Address
Cardholder's Signature
ORDER DATE

Escan Technologies Corp.
12140 Severn Way, Riverside, CA 92503
Toll Free (800) 653-4252 * Int'l (951) 270-1911 * FAX (951) 270-0920

NAME
COMPANY
SHIP TO:
Street Address, Suite # No P.O. Box
City, State, Zip Code
Country

BILL ADDRESS:
Street Address or PO Box
City, State, Zip Code
Country

PHONE/FAX #
EMAIL

ITEM #	PRODUCT DESCRIPTION	QTY	PRICE	TOTAL















	SubTotal			_______
	Sales Taxes 7.75% (only California orders)			_______
	Shipping & Handling			_______
	TOTAL