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T H l S F O R M IS FOR U.S. CUSTOMERS O N L Y . OVERSEAS CUSTOMERS SEE YOUR DISTRIBUTOR.
EXPEDITED P A R T S ORDER FORM
(FOR REPAIR PARTS ONLY)
L
1
N A M E
ADDRESS
CITY
STATE
ZIP
I
I
K I T M O D E L
PURCHASE D A T E
I N V O I C E N U M B E R
L O C A T I O N PURCHASED
PLEASE D O N O T WRITE I N T H I S SPACE
SEND
HEATH COMPANY
BENTON HARBOR,
MICHIGAN 49022
ATTN PARTS REPLACEMENT
DESCRIPTION O F P A R T
T O T A L
PRICE
I
QTY.
-
r
INSTRUCTIONS:
I N C L U D E CHECK O R M O N E Y ORDER F O R T O T A L PARTS O R D E R E D A D D 10%
( M I N I M U M $0.25) F O R INSURANCE, POSTAGE A N D H A N D L I N G .
A U T H O R I Z E PERMISSION FOR C.0 D. SHIPMENT ( M I N I M U M ORDER SHIPPED
C.0.D
IS $10.00).
M I C H I G A N RESIDENTS A D D
4%
SALES T A X
rn
I
DESIRED M E T H O D
OF SHIPMENT
EDITORS I N I T I A L S
H E A T H
P A R T
NUMBER
I
C.O.D.
A U T H O R I Z A T I O N
S I G N E D
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