Print this page and mail with your check or credit card information to:

Zoologic Research, Inc
PO Box 45445
Phoenix, AZ 85064

Buggy Beamer ®  Order form

Quantity

Type

Amount
________

TWO Buggy Beamer ®  Roach Traps with cartridges
Price $29.90 plus S&H of $8.95 (total $38.75)

$__________
________ When ordered with the above: Four Replacement Cartridges
Price $19.80 Plus no extra S&H 		$__________
  Sales tax (AZ residents only) add 7.7% of total sale $__________
  Total Purchase $__________
Shipping Address:


Name: _____________________________________


Address: ____________________________________


City/State/Zip: ________________________________


Evening Phone: ______________________________


Email address: (optional) _________________________

Check or money order is enclosed:
Make out check to Zoologic Research INC ___________

OR

Charge to my credit card:


1. Type of credit card (check one)
 
Visa Master Card American Express Discover
       


2. Acct# _____ ______ ______ ______

3. Expiration Date ________ (mm/yy)

4. Signature _______________________________

5. Is the address on your credit card EXACTLY the same as your
 shipping address? (it MUST be exactly the same or the approval will not go through!)

(yes or no) _____________________

6. If the address on your credit card is different from Shipping address please fill out below:

Name: _____________________________________

Address: ____________________________________

City/State/Zip: _____________________________

Day Phone: ______________________________

Return to Buggy Beamer ®  Home page