Please print out the following form, complete it,
and fax to 1-877-709-0721
You may also send questions or orders to
roseredmond@sbcglobal.net or call 616-399-5520
Adaptive Materials for Independence
16531 Greenly St.
Holland, MI 49424
SHIP TO: (NO P.O. BOXES, PLEASE)
BUSINESS ______________________________________
ATTN: _________________________________________
ADDRESS _____________________________________
CITY ________________ STATE_______ ZIP _________
PHONE (____)___________________________________
BILL TO: SAME AS ABOVE
BUSINESS ______________________________________
ATTN: _________________________________________
ADDRESS ______________________________________
CITY ________________ STATE_______ ZIP ________
PHONE (____)___________________________________
PAYMENT METHOD:
Check or Money Order Enclosed
(make payments to: Adaptive Materials for Independence)
Purchase Order Enclosed (#___________ )
No credit cards are accepted at this time.
When order is shipped you will be invoiced for the amount due including the S & H charges. Allow up to 4 weeks for delivery.