Tyless TM Fax, Mail
Order Form
                          Ship To:                                                                                        Bill To: (If Different)


Name:
  ___________________________________________    Name:  _____________________________________________



Company:  _________________________________________ Company:  __________________________________________



Address 1:  ________________________________________   Address 1:  _________________________________________



Address 2:  ________________________________________    Address 2:  _________________________________________



City:  ______________________________________________ City:  _______________________________________________



State:  
_______       Zipcode:  __________________________  State:  ______      Zipcode:  _____________________________



Email Address:  ___________________________________   Telephone:  
__________________________________________   
                      
If paying by credit card, please provide Credit Card information below.  MC, Visa, AMX, Discover accepted
Credit Card Number:  _________________________________________________                 Credit Card type:  ______________       
                                                                                                                                                        (MC, Visa, AMX, Discover)  
       


Credit Card Expiration Date:  _________________________                                Fax To Tyless at:  541-344-1579


Amount Authorized:   _______________________                                                  Mail to Tyless at:    Tyless
                                                                                                                                         P.O. Box 11205
                                                                                                                                         Eugene, OR  97440  
  

Signature:  _________________________________________

                                                                                                                           Orders with personal checks will ship after check
                                                                                                                                                             clears
bank.                                                             
                                    Pricing:

                                        Length of Cord




Number
of
Cords



Prices shown are total cost including shipping & package
White
 
Black
 
Gray
 
Brown
 
Total Quantity
 
Color                     Quantity
Cord Length          __________________

Number of Cords   __________________
  25"
32"
37"
42"
10
$9.65
$11.25
$12.80
$13.85
20
$14.70
$17.25
$19.60
$21.45
50
$27.70
$32.80
$37.40
$41.10