Antiscald Inc.

FAX / MAIL ORDER FORM

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All returns must have a Return Authorization Number. Please contact us if you wish to return a item. We will charge a mininum 10% restocking fee if you return an item, and shipping costs are not refundable.

ALL information on the form must be clear and legible - any information missing will prevent your order from being fulfilled.

AntiScald Inc. will only accept returns FOR PRODUCTS THAT ARE DEFECTIVE within 30 days from date of purchase for a full product refund applicable to all Products.

PRICES DO NOT INCLUDE SHIPPING CHARGES
Please be sure to add shipping charges
to avoid your order being delayed.

Please print this page and fax your order to us at (718) 263-1259 or mail it with a check or money order to:
AntiScald Inc. - Attn: Esther Stein
70-40 137th St.
Flushing, NY 11367-1949 USA

ScaldShield Shower 14110	QTY @ $34.99	ScaldShield Tap 14108	QTY @ $34.99
ScaldShield Bath 14109	QTY @ $34.99	Scaldshield Mini TMV With Fittings 14111	QTY @ $99.65
Scaldshield Domestic - PLEASE CALL US AT (718) 268-7126 TO ORDER THIS PRODUCT

CREDIT CARD INFORMATION
Card Type	VISA MASTERCARD DISCOVER AMERICAN EXPRESS
Card Number	Expiration Date
Name On Card	3-Digit # on Back of Card
Telephone Number
Address
Address 2
City	State Zip

SHIPPING INFORMATION
SHIP TO: SAME AS CARDHOLDER

ORDER AMOUNT
SHIPPING & HANDLING COST	1 Item = $4.50 / $1.50 for each additional Item
SALES TAX (NY Residents Only)	8.65% x ORDER AMOUNT
TOTAL AMOUNT
CARDHOLDER SIGNATURE
E-MAIL ADDRESS

THANK YOU FOR YOUR ORDER!