Please print this Order Form and fax or mail it to us

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Name: ______________________________________
Street Address: _______________________________
Apt/Unit #: __________________________________
City: _______________________________________
Prov/State: __________________________________
Country: ____________________________________
Postal/Zip Code: ______________________________
Phone Number: _______________________________
Fax Number: _________________________________
E-Mail: _____________________________________

Printer make & model: _________________________
Cartridge #'s: _________________________________
Description: __________________________________
___________________________________________
___________________________________________
Price: $_____________________________________

Lower your cost by doubling your ink. Only $13 cdn, $9 U.S. per kit Yes_______ No_______

Shipping method, please check:
_____Canada - Parcel Post $6.00
_____Canada - XPress Post $10.00
_____U.S.A. - U.P.S. $8.00
_____U.S.A. overnight - $17
_____International - Airmail $18.00

US orders - no tax
Canadian orders - In Ontario PST & GST - Outside Ontario, only GST

Total Invoice: $____________________

Payment Type: Please Circle

Visa/Mastercard - Cheque - Money Order

Visa/Mastercard # _______________________
Name on card: __________________________
Expiry Date: ____________________________

Please Make the Cheques or Money Orders out to:

imagnan corporation
99 Fifth Ave. Suite 191
Ottawa, Ontario, Canada
K1S 5P5

Tel: 613-234-0639
Fax: 613-230-8357
Toll Free Order Line: 888-827-3345

E-mail: sales@imagnan.com