Portables Plus

		January 6^th, 2009

CATALOGUE REQUEST

If you wish to receive any of the products below, please enter the quantity you wish to receive and fill in the form below.

We are pleased to send up to a maximum of 3 catalogues/flyers per customer at no charge, but higher quantities will incur extra fees.

Please note that fields marked with ** are required.

PROVIDE YOUR INFORMATION BELOW
First Name: **
Last Name: **
Company Name: **
Customer Number:
Address: **
City: **
Province / State: **
Postal / Zip Code: **
Country: **
Telephone: **
Fax:
Email Address **