USE THIS FORM TO CREATE AND ORDER A CUSTOM CABLE

MORE INFORMATION: (863) 699-1231   ORDER DIRECT: (800) 444-1995

FAX TO: (863) 699-0360       EMAIL TO: whobbies@strato.net

Name: _________________________

 

Cust. #: ________________________

 

Phone #: (         )- _______-_________

 

Ship To:

Street: _________________________

City: __________________________

Zip: _____________

 

Payment: VISA, M/C, DISC, AMEX

         (circle one)

 

Card #: _________________________

Exp Date: ________________

3-4 Digit Code: ___________