P O Box 183
313 Casement Road
Whangamata NZ
PH (07) 865 9647
Fax (07) 865 9649
Email: [email protected]
Web: www.staydry.co.nz
ORDER FORM
Name____________________________________ Order No (if applicable) ______________
Date_________________________________
Street Address (NOT - P.O. Box – unless ‘standard post’ option is selected)
________________________________________
Phone _______________________________
________________________________________
Order taken by _______________________
Delivery name & address: (only if different to the above)
Name:___________________________________ Phone No_____________________________
Address__________________________________________________________________________
Item #
Description
Qty
Size
Colour
1st choice
Colour
2nd choice
Price
Sub Total
Comfy Bed Pads Add 1 long tuck-in flap (add $5.00 to price ) - Add 2 long tuck in flaps (add $10.00 to price)
PLEASE SELECT YOUR DELIVERY OPTIONS BELOW:
Postage & Packaging:
(small parcels – less than $100 )
$6.00
Postage & Packaging:
(Parcels – more than $100 )
$7.50
Postage & Packaging: North Island
( Parcels – more then $200 )
$12.00
Postage & Packaging: South Island
(Parcels – more then $200)
$17.00
If you are on ‘Rural Delivery’ ( Please allow an extra day for delivery)
add $4.30
Please enclose cheque or fill out ‘credit card’ details below
Total
Have you added the ‘delivery fee’ to your order????
Payment Details: Please tick box.
[ ] Cheque
[ ] Credit Card
[ ] Mastercard
[ ] Visa
Expirey Date:________________Card Holders Name:________________________________________
Card Number:____________________________________Card
Secuity Code____
Please fill in these details:
If you have ordered from us before – Please tick the following box [ ]
Age Group:
[ ] under 40 [ ] 40-60
[ ]60-70
[ ] 70-90
How did you first hear about Stay Dry Products? [ ]Through a friend [ ]Advertisement (please specify below)
[ ] Search Engine
[ ] Yellow Pages [ ] Continence Nurse or District Nurse [ ] Other
If ‘other’ or ‘advertisement’ please specify___________________________________________________________
Total