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| SHIP TO: | _____________________________ |
Date:
________________________
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Customer Name:_________________________________________________________________ Agency:________________________________________________________________________ Address: _______________________________________________________________________ Address 2: _____________________________________________________________________ City: __________________________________________State:_________Zip:________________ Phone: _______________________________________Fax:______________________________ Email Address: __________________________________________________________________ |
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| METHOD OF PAYMENT: | ||||||||||||||||||||||||||||||||||||||||||
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Purchase Order Number:___________________________. Check Enclosed for $_______________payable to The Public Safety Group. (U.S. Funds ONLY)Credit Card: VISA MASTERCARD Expiration Date _______/_______ Credit Card Numbers: ____________ - ____________ - ____________ - ____________ Authorized Signature:
____________________________________________________ |
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