<% ' FP_ASP ASP Automatically generated by a Frontpage Component. Do not Edit. On Error Resume Next Session("FP_OldCodePage") = Session.CodePage Session("FP_OldLCID") = Session.LCID Session.CodePage = 1252 Err.Clear strErrorUrl = "" If Request.ServerVariables("REQUEST_METHOD") = "POST" Then If Request.Form("VTI-GROUP") = "0" Then Err.Clear Set fp_conn = Server.CreateObject("ADODB.Connection") FP_DumpError strErrorUrl, "Cannot create connection" Set fp_rs = Server.CreateObject("ADODB.Recordset") FP_DumpError strErrorUrl, "Cannot create record set" fp_conn.Open Application("_ConnectionString") FP_DumpError strErrorUrl, "Cannot open database" fp_rs.Open "", fp_conn, 1, 3, 2 ' adOpenKeySet, adLockOptimistic, adCmdTable FP_DumpError strErrorUrl, "Cannot open record set" fp_rs.AddNew FP_DumpError strErrorUrl, "Cannot add new record set to the database" Dim arFormFields0(0) Dim arFormDBFields0(0) Dim arFormValues0(0) FP_SaveFormFields fp_rs, arFormFields0, arFormDBFields0 fp_rs.Update FP_DumpError strErrorUrl, "Cannot update the database" fp_rs.Close fp_conn.Close FP_FormConfirmation "text/html; charset=windows-1252",_ "Form Confirmation",_ "Thank you for submitting the following information:",_ "faxorder.htm",_ "Return to the form." End If End If Session.CodePage = Session("FP_OldCodePage") Session.LCID = Session("FP_OldLCID") %> Amdrecor Fax Order Form

AMDRECOR, INC.    |    Print & Fax Order Form    |    Fax # (713) 688-5636
This form is provided online for the convenience of those customers who prefer not to use the secure online system or by phone. Fill in the form, print and fax to Amdrecor, Inc. at 713-688-5636 or call 800-356-2938.
 

Bill To

 Credit Card Holder Name Required

Your Name:
Address 1:
Address 2:
City:
State: Zip:
Credit Card # :
Expiration: Telephone # (required):
Email Address:

Ship To

 Same as "Bill To" address? YES  / NO (enter below)
Company/Name:
Address 1:
Address 2:
City:
State:   Zip:
Special Shipping or Processing Note:
QTY ITEM # DESCRIPTION AMOUNT TOTAL

HF3 Protector Head Frame
RS1 Re-Usable Shield
DS2 Disposable Shield 12pk
ES2 Eyeglass Side Shield
FS-1 Face Shield Kit

Sub-Total:

   

Tax (8.25% Texas residents only):

   

Shipping/Handling (see S/H Chart here):
   

Total:

Signature: ____________________________ Date: ___________