Prism FIlters Order Form


	8822 Cypress Woods Lane
	Olive Branch, MS 38654
	800-594-9010
	ORDER FORM	[ Home ]

Customers who prefer to send order by mail may print this form, complete it, and send to the above address

Please complete the form below and click on the submit button.
Please click only once as multiple clicks will generate multiple orders

QTY DESCRIPTION

FS114 Prism Water Filter System (filter elements incl.)       $89.95 ea.
114SF Sediment replacement cartridge                              $11.50 ea.

114CB Carbon block replacement cartridge                       $14.00 ea.

114FSET 1 Sediment & 1 Carbon block replacement cartridge      $21.50 set

MS residents check here. 7% sales tax will be added to the total cost of your order.

UPS Ground S&H included FREE

BILL TO:

Credit Card

Cardholder Name as it appears on card

Card Number no dashes or spaces

Expiration Date mm/yy

SHIP TO:

Name

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Phone #

Email Address

QTY	DESCRIPTION
	FS114 Prism Water Filter System (filter elements incl.) $89.95 ea.
	114SF Sediment replacement cartridge $11.50 ea.
	114CB Carbon block replacement cartridge $14.00 ea.
	114FSET 1 Sediment & 1 Carbon block replacement cartridge $21.50 set
MS residents check here. 7% sales tax will be added to the total cost of your order.

BILL TO:
Credit Card
Cardholder Name		as it appears on card
Card Number		no dashes or spaces
Expiration Date	mm/yy

SHIP TO:
Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Phone #
Email Address

Site created by BennettMedia.comCopyright © 1999 Payne Manufacturing, Inc. All rights reserved. Revised: October 20, 2000

Site created by BennettMedia.com
Copyright © 1999 Payne Manufacturing, Inc. All rights reserved.
Revised: October 20, 2000