visit our Valentino site: valentinopads.com
phone 800.659.6073 or 704.521.1088 - fax 704.521.1099 


Order Form
Date: 
    
Customer No. 
P. O. Number: 
Name: 
Billing Address: 
City: 
State/Province: 
 
Zip/Postal Code: 
Country: 
Phone: 
Fax 
Email: 
Shipping Address if Different from Billing Address:
Shipping Address: 
    
City: 
State/Province: 
Zip/Postal Code: 
Country: 
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Quantity
Product #
Description
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Bill to Credit Card on File
Call me for Payment Method
Special Instructions: 
  You will receive a copy or your order via email.

 

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