Conventional
order form
To use this order form just print it out, fill it out, then
mail or fax with payment or credit card information to:

Child Safety-Net
c/o SurfSafely.com
118 Belden Rd
Burlington, CT 06013

Fax 860-673-7431
Quantity ordered ________ x $19.95 ea. __________ (ext total)
 
6% Tax (CT only)
 __________
 
Shipping and Handling
$3.90 ea USA, $15.00 ea Int'l
 __________
 
Amount enclosed
 __________

Comments:

 
Bill to information
Name ____________________________________________________
Address ____________________________________________________
City ____________________________________________________
State _______
Zip ______________
  
Ship to information
(Only if different from Bill to)
Name ____________________________________________________
Address ____________________________________________________
City ____________________________________________________
State _______
Zip ______________
  

Payment (check one)
MC ___ Visa ___ Personal Check ___    (Make checks payable to "New England Webmasters." Allow up to 10 business days for checks to clear.)
Card Number ___________________________ Exp. _______________
Signature        ___________________________ Date _______________