AGM Therapy Mats  
Order Form
175 Rickey Blvd - Bear, DE 19701
FAX (302) 836-1101, Toll Free 1800-367-1980, Email: sales@therapymats.com

SOLD TO:
Name:______________________________________
Address:___________________________________
City:________________________ State:_______
Zip:____________ Phone:____________________
SHIP TO:
Name:______________________________________
Address:___________________________________
City:________________________ State:_______
Zip:____________ Phone:____________________
ITEM
NO.		 QTY DESCRIPTION - PRICE EACH TOTAL PRICE
. . . $ $
. . . $ $
. . . $ $
. . . $ $
. . . $ $
. . . $ $
. . . $ $
. . . $ $
         
[__] Check Enclosed

$______________


Sub Total $
Shipping $
Total $
* Never include credit card information on this order form. A friendly sales associate will contact you for all credit card orders.