COIN GUARD™ PURCHASE ORDER/INVOICE

FOR CONVENIENCE AND SECURITY
We have prepared a secure form or you can
PRINT PAGE, COMPLETE CLEARLY AND FAX TO (954) 791-4710

COMPANY CHECKS PAYABLE TO: COIN GUARD, INC. P. O. BOX 460460 FORT LAUDERDALE, FL 33346 (954) 792-7000 (800) 505-4645	P. O.: #________________________________ DATE: _________________________________ CONTACT PERSON: _____________________ PHONE: ( )__________________ FAX: ( )__________________

BILL TO: ________________________________ ________________________________________ ________________________________________ ________________________________________	SHIP TO: ______________________________ _______________________________________ _______________________________________ _______________________________________

Circle Method of Payment: C.O.D. Mastercard Visa American Express Company Check Card # __________ - __________ - __________ - __________ Exp. Date _____ / _____ Name on card: ________________________________________________________ Credit Card billing address: __________________________________________________ __________________________________________________ ____________________________________ ZIP Code: ___________

DESCRIPTION

PRICE (ea)

QUANTITY

TOTAL AMT.

24mm Coin Guard w/ install kits
(Fits U.S. Quarters)

$19.95 X

____________ =

$_______________

28mm Coin Guard w/ install kits
(Fits currency up to 28mm diameter)

$19.95 X

____________ =

$_______________

24mm first orders come with rivets and bolts (to see which you prefer).
28mm comes with bolts only.

SHIPPING AND HANDLING CHARGES FOR ALL SHIPMENTS
Quantity (each)	Shipping for: AZ, CA, ID, MT, NV, OR, UT, WA, NY	Shipping for all other states
5ea	$12.70	$8.99
10ea	$15.00	$9.38
20ea	$18.70	$9.98
35ea	$24.00	$10.73
50ea	$30.70	$13.08

S/H
Invoice Total

$_______________
$_______________

Thank You For Your Order!

Coin Guard™
(800) 505-4645 (954) 792-7000 (954) 791-4710 FAX
www.coinguard.com