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ORDER FORM


KEY CODE


CUST. #


Call Toll Free: 1.800.624.7968 • Shop Online: HatchEarlyChildhood.com Fax Toll Free: 1.800.410.7282 • Mail: P.O. Box 11927, Winston-Salem, NC 27116


Item # Page # Description  Quantity Color Price Each Total Price


Payment Method Mastercard


VISA Account Number


Freight, Tax & Totals


Am. Express Discover


Cardholder’s Organization (if listed on card) Cardholder’s Name (Please Print) Authorizing Signature


Open New Account Bill Existing Account


Exp. Date A. Subtotal


B. Freight Charges if any truck


included, see regional minimum on page 37


A $55.00 surcharge will be added for driver assistance.


Security Code (see back of card)


Address (Cardholder’s billing address required — must match card) Check Enclosed #


PO # BILL TO (please print):


Organization ATTN


Address


City, State, Zip Phone (


) *SHIP TO (please print):


Organization ATTN


Address


City, State, Zip Phone (


) Email *Ship to Address cannot be a P.O. Box [ 36 ] 800.624.7968 Fax ( ) Fax ( ) Same as BILL TO Job Title Cancel items if out of stock? Substitute a like item if out of stock?


yes yes


Duplicate or previously submitted order? yes Are you a new customer?


yes SAVE! Check here for Special HATCH® Email


no no no no


e-offers! Job Title Promotional Code Thank you for your order! for truck  items Inside Deliver


Expedited Shipping Call for quote-not available


C. Additional Shipping Total S D. Sales Tax Total


ee details on page 37  items


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