Paul Charbeneau Enterprises: Online Order Form

Online Order Form

Instructions: Please fill out and submit the form below for each product you wish to purchase. An asterisk (*) denotes required information.

US Government Agencies: Credit card orders are shipped within 48 hours. For purchase orders with an authorized P.O. number, your order will be shipped immediately. Please forward a copy of the order to our office and be sure to include your P.O. number in the field provided. For purchase orders without an authorized P.O. number (authorization pending), we will package your order and ship it upon receipt of a valid P.O. at our fax number or mailing address. Government agencies may not use the "remit upon receipt" payment method.

All orders are shipped via US Post Office Priority Mail free of charge. For alternate delivery methods, please contact us.

Security Note: This form is not currently being submitted using a secure transmission. If you are using a credit card and do not wish to send your number unsecured, you may select the appropriate card type, leave the number and expiration data blank, submit the form, and call our office with the card information.

Your Name: *

Email Address: *

Office Phone: *

Office Name as you would like it to appear within the software you are ordering:

Shipping Address

Company / Agency: *

Address Line 1: *

Address Line 2:

City, State & Zip: *

Attention: *

Billing Address (if different from address above)

Address Line 1:

Address Line 2:

City, State & Zip:

Attention:

Product and Quantity

Product: *

Quantity: * (applicable to OHA-7 product only)

Payment Method *

US Government Purchase Order (authorized)
US Government Purchase Order (pending)

P.O. Number:

MasterCard
VISA
American Express
Discover

Card Number: Expiration (mm/yy):
Cardholder Name:

Remit upon receipt (check or money order / non-government agencies only)

Special Instructions:

Paul Charbeneau Enterprises
P.O. Box 460843
Aurora, CO 80046

(303)617-3430 (voice)
(303)627-9958 (fax)

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