Order Form / Sheet Please fill out the form and fax it back to us   Fax form to 1(866) 799-3930
1.Phone (In case we need to call you about your order)     Daytime  _________________ Fax     ___________________ Evening   _________________ E-mail ___________________
2. Ordered By       Is this being delivered to(Circle One)?: Home Business/Office   Name First  ___________________ Last _______________
3.Address (Billing)  ____________________________________ Apt/Suite  _________       City  _____________ State  _______________ Zip Code  _________
4. Ship To: If different from information above.   Name First  ________________ Last _______________
Address (Billing)  ____________________________________ Apt/Suite  _________   City  _____________ State  _______________ Zip Code  _________
5. Method of Payment (Circle One) Credit Card Money Order
Please Make Money orders payable to: Lelo Uniforms Company
Credit Card (If ordering by credit card, please fill in the following information)
Credit Card #  ________________________________ Expiration Date    _________
Card Type(Circle One below)     3 or 4 Digit Code* ________         Visa MastercardDiscover Discover American Express
*Printed of Back of Visa, MC and Discover (3 Digits)
*Printed in Front of American Express(4 Digit)
Name as it appears on Card First  ___________________ Last _________________
Signature  ___________________
Product Name Color Size Quantity Price Each Total
Value of Order Shipping Up To $14.99 $7.50 $15.00 to $25.99 $8.50 $26.00 to $49.99 $10.50 $50.00 to $74.99 $12.50 $75.00 to $99.99 $13.50 $100.00+ FREE! Next Day Air Add $14.50 2nd Day Air Add $8.50 Puerto Rice (PR), Hawaii (HI) and Alaska (AK)  Add $8.50		Sub Total:   Shipping & Handling   Order Total
Thank you for your order!