FAX Order Form
Complete this form and FAX to 1-860-295-0142. Be sure you have read our Terms of Sale & Return Policy.
"*" = Required Information
-------------------------- BILLING INFORMATION: -----------------------


_______________________________________________________________________
Company Name                                           

______________________________   ________________________________   ___
*Last Name                       *First Name                         MI

_______________________________________________________________________
*Street Address

_______________________________________________________________________
Street Address

__________________________  ______________________   __________________
*City                       *State or Province       *Zip / Postal Code

________________________  _________________________  _____
*Country                  *Daytime Telephone Number  Ext.

________________________  _____   ________________________  _____
Evening telephone number  Ext.    FAX telephone Number      Ext.

________________________________________
Other phone number and type (Car, Pager)

_______________________________________________________________________
*E-mail address

Discover, Visa, MC, Amex  ________-_______-_______-_______  ____/______
(Circle one of the above) *Credit Card Number               *Mth  *Year

______________________________  _______________________________________
*Name as it appears on card     *Name of credit card issuer (i.e. Bank)

*Telephone number on back of card:  _________________________________

*3 or 4 digit code appearing on card, next to signature:  ________


--------------------------- ORDER INFORMATION -------------------------

Please use ONLY the seven digit BLT Item Number from our website.

I am purchasing the following items from the BLT catalog:
(Item #'s begin with B or C)

Qty __ Item# __ __ __ __ __ __ __   Qty __ Item# __ __ __ __ __ __ __

Qty __ Item# __ __ __ __ __ __ __   Qty __ Item# __ __ __ __ __ __ __

Qty __ Item# __ __ __ __ __ __ __   Qty __ Item# __ __ __ __ __ __ __

Qty __ Item# __ __ __ __ __ __ __   Qty __ Item# __ __ __ __ __ __ __

Qty __ Item# __ __ __ __ __ __ __   Qty __ Item# __ __ __ __ __ __ __

*I would like my order shipped via:

United States Only:
(__) Ground (contiguous 48 states only)
(__) FedEx Priority Overnight
(__) FedEx Standard Overnight
(__) FedEx Economy 2nd Day
(__) FedEx Saver 3 Day (contiguous 48 states only)
(__) Express Mail (AA, AE, AK, AP, AS, FM, GU, HI, MH, MP, PR, 
     PW & VI only)
(__) Priority Mail (AA, AE, AK, AP, AS, FM, GU, HI, MH, MP, PR, 
     PW & VI only)

Outside the United States Only:
(__) FedEx International Priority
(__) FedEx International Economy
(__) Global Express Mail
(__) Global Priority Mail
(__) Air Mail


*Please Select One:
(__) Bill FedEx to my FedEx account: __ __ __ __ - __ __ __ __ - __
(__) I authorize the appropriate shipping charge, if any, to be added
     to my order.
(__) E-mail me and wait for approval of an estimated shipping charge.


Please ship my order to (if different than billing, no P.O. boxes):
(NOTE: If the shipping address you supply is not the same as your 
credit card billing address, or is not on file with your credit card
company as an alternate shipping address, your order will not be 
processed.)

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________


I have read and agree to the terms of this sale as described in BLT's
Terms of Sale & Return Policy, and authorize BLT or its agent to charge 
the indicated credit card the sale amount of the item(s) indicated 
above, plus shipping and handling, if any.


X_____________________________________________   ____ / ____ / ________
 *Signature                                      *Month *Day   *Year

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