Order Information
Phone:  (800) 881-7345
Fax:   Print this form and fax it to (252) 946-0371
Mail:  Send this form to

North CarolinaPI.com-1530 S. Evans St. Suite 209-Greenville, NC  27834

Order Form

Service	#	IH	Price	Qty.	Total
				Subtotal
				Total

Address

Name
Address
City/State		Phone
Zip		Fax
E-mail

Billing Address
  Check if same as shipping address

Name
Address
City/State		Phone
Zip		Fax
E-mail

Billing Information

Credit card
Name on Card
Card number
Expiration