Child Technologies, Inc.
4010 Calhoun Ave.
Chattanooga, TN 37407

Print out this form,
then mail or fax it to Child Technologies.

Phone Toll Free: 877-867-3171 Fax: 423-867-1344
BILLING INFORMATION SHIPPING INFORMATION

_____________________________________________
Institution/Company Name


_____________________________________________
Institution/Company Name

_____________________________________________
Individual Name


_____________________________________________
Individual Name


_____________________________________________
Street Address
_____________________________________________
Street Address

_____________________________________________
City, State, Zip Code


_____________________________________________
City, State, Zip Code

Phone:___________________
Fax:________________
Email___________________
PO#_________________

Catalog #

 Qty Description Unit_Price Total_Price
Payment Method
purchase order #____________________________________________________

Check or money order enclosed ________

Visa / MC / Am Express / Discover . (circle one)

Card No. ________________________________ Exp. Date _____________

Signature__________________________________________________________

Cardholder's Name / Address_________________________________________

__________________________________________________________________

Subtotal

 

Sales Tax
TN Residents Add 8.25%

 
Call for freight quote

 
Total

 

These items are manufactured to order. Orders cannot be cancelled.

We’d be happy to assist you with any questions you may have, please call us toll free at 877-867-3171.