Student Assistance Services Corporation Order Form - DoIt4URLungs Escape the Vape Kits

 
 
Name _________________________________________        (if using card, name as it appears on card)
 
Company Name__________________________________________
 
Address:_______________________________________________
 
City_______________________  State _________  Zip _________
 
Telephone: _______________________
 
If shipping address is different from billing address, please indicate shipping address below


________________________________________________________________________________________

 

 _________________________________________________________________________________________                                     
 
 
Number of kits ordered:_______ @ $600 per kit, total amount: ____________
 
 
Credit Card # ______________________________
 
Visa/MC/AMEX (circle one)   Security Code _________       Exp. Date:________________        
 
 
OR PO #        ___________________
 
 
Date Ordered:__________________
 
 
Date Needed: ______________________________
 
 
Signature:______________________________________

Email to: Cdannibale@sascorp.org