CACC Inquiry And/or Order Form

Please provide the following contact information:

*First Name*
*Last Name*
*Organization*
*Street Address*
*Address (cont.)*
*City*
*State/Province*
*Zip/Postal Code*
*Country*
*Work Phone*
*FAX*
*E-mail*
*URL*

Please provide the following ordering information:

BILLING

Purchase Order #

Account Name

Is Shipping address same as Billing address?
Yes No

SHIPPING

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country
Choose one of the following color options for Frame

Choose Color option for Seat, Pouch and Handle pad cover:

Select any of the following options that apply:

Canvass Style Seat
Lounge Style Seat
Canopy for outdoor use
DVD Player
CD Player
Tray 
Portable (for personal use) 

Would you like a call back?


Yes 
No




Select any of the following options that apply:
Interested in buying Kiosk/Corral Package
a Business Sales Package                                                     
Personal Use
Maintenance Plan
Extended Warranty                                                                
Other

	SHIPPING
*Street Address*
*Address (cont.)*
*City*
*State/Province*
*Zip/Postal Code*
*Country*

	BILLING
*Purchase Order #*
*Account Name*

CACC Inquiry And/or Order Form

Copyright©2006 Man-Stroller/CACC© All Rights Reserved[ [Div of Blanchard Machine, LCC]. Revised: 09/06/06

Copyright©2006 Man-Stroller/CACC© All Rights Reserved
[ [Div of Blanchard Machine, LCC].
Revised: 09/06/06