S.I. ROSATI ORDER FORM (Please print) Name:__________________________________________________ Date: ______________ Street Address: ____________________________________________________________ City / State / Zip: ________________________________________________________ Phone: (____)_________________________ Fax: (____)_________________________ ___ Contact me for a service call ORDER: Electrostatic Air Filter (size ____L x ____W x ____TH) 1" standard Qty ____ @ $69.95ea. ________ 1" Microbial Gold Qty ____ @ $79.95ea. ________ 2" standard Qty ____ @ $94.95ea. ________ Special size order filters (not listed) add $10.00 Custom Price $__________ Sales Tax (CA only) ________ Total Price $__________ Multiple orders receive a 10% discount. Credit Card __Visa __MasterCard __Discover Number:_________________________ Exp. Date:_____________ Name on Card (if different):________________________ Credit Card Billing ZIP Code:__________________________ Check or money order should be made payable to S.I. Rosati. Money orders are shipped immediately; checks are held 10 working days. Please allow 10-14 days for delivery. Mail To: S.I.Rosati P.O.Box 1122 Alta Loma, California 91701 Phone: (909) 987-7000 * Fax: (909) 987-5580 * Email: jeff@sirosatiair.com http://www.sirosatiair.com