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  Order Form for Acrylic Practice Blocks for Cerec® Machines
Product # PiBlock
Quantity (please mark one):
  10 @ $8.00 each = $80
  20 @ $7.00 each = $140
  50 @ $6.00 each = $300
  100 @ $5.00 each = $500
  More than 100; desired quantity ; we will quote.
Shipping Options (please mark one):
No shipping fee for prepaid orders sent via first class mail.
via USPS First Class Mail (usually 2-4 days) $5
via USPS Express Mail (overnight) $15
Payment Options
 Product Total:      $0.00
 Shipping:             $0.00 
 Order Total:         $0.00
Prepaid
Invoice
Billing Information
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Company
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Address 2
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  Click here if Billing and Shipping information are the same
Shipping Information
First Name  *
Last Name  *
Company
Address 1  *
Address 2
City  *
State  *
Zipcode  *
Email  *
Telephone  *
Fax
Orders accepted via phone, fax, email, or mail.
Credit cards accepted via PayPal.
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