KroTek Electronics Cheque Order Form

This order form is included for your convenience if ordering by check. Just print it out, fill it in, and send it along with your check to:

KroTek Electronics
4742 Dugas
Pierrefonds, Quebec, Canada
H9J 2B7


Name	_____________________________________________
Address	_____________________________________________
	_____________________________________________
City	_____________________________________________
State/Province	_____________________________________________
Country	_______________________
Postal/ZIP Code	____________________
Daytime Telephone	_____________________
Email Address	_____________________________________________

Model Number	___Model 1 (Please check one) ___Model 2 ___Model 3 ___Model 4 Note: For Chrono Lisa model details, please consult our Products page
Quantity	___ @ US$ 59.00 each = ___________
Shipping and Handling	___ @ US$ 15.50 each = ___________
Total	___________

Payment Method	Check enclosed

Please tell us how you heard about KroTek Electronics	_____________________________________________ _____________________________________________ _____________________________________________

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