Order Form

Print it out, fill it in, and fax it to us.

www.syscontech.com

Ship To:
- Name
- Address
- Address
- City/State/Zip

Part No................ Description ............................................................... Quantity ....... Net Price Each ... ............. Extended Price ..............

Order Charge is $6 if less than $600 of product (or $8 if less than $50 of product.)

Sales Tax applies to California shipments by county. LA - 8.25%; Orange, Riverside, San Bernardino, San Diego, - 7.75%, all other counties - 7.25%. Mass. Sales Tax - 5%.

Shipping charged at actual cost. UPS Ground is standard. You may specify an alternate:

Special Instructions

Contact Information - Name: . . . . . . . . . . . . . . . . . . . . . . Phone No. . . . . . . . . . . . Fax No. . . . . . . . . .

Purchase Order No. (if required)

Billing Information for Purchase Order or Credit Card:
- Name
- Address
- Address
- City/State/Zip
- Fax Number for Invoice Copy

Credit Card Number, Expire Date (MM/YY), and Security Code

We need the correct billing address for the credit card. The 3 digit security code can be found on the back of the card in the signature strip.

SysCon Technology, Inc.
31500 Grape St #3-289, Lake Elsinore, CA 92532

sales@

syscontech.com

FAX (877) 683-1721

Revised
6/30/07