Fax Order

"Hy-Tech Insulating Paints & Paint Additives": Print and FAX Order To: (321) -984-1022
Or Mail to: Hy-Tech, P.O. Box 216, Melbourne, FL 32902, U.S.A.

Quantity	Description	Price Ea.	Total Price








		Sub Total
Shipping Cost (can be calculated from shopping cart)
Total

Payment Method:	_____ Visa	_____ MC	_____ AMEX	_____ PayPal
Credit Card #:____________/____________/____________/____________ Expires: ____ /____
Using PayPal?	Your PayPal Account email
Please Print Name on card
Billing Address: (address where you receive credit card statements)


Shipping Address: (if different from above)


E-mail Address:		Daytime Phone Number (required):
CREDIT CARD AUTHORIZATION Charge my credit card in the amount of:___________________ I understand that I am authorizing Hy-Tech to charge my credit card for the purchase(s) I have made above. Signature:__________________________________________ Date:________________ Amount charged on your credit card will show up on your statement as Hy-Tech