AirMax Breather™ Mail Order Form Small Quantity Mail Orders (1 - 49) PLEASE PRINT A DUPLICATE COPY FOR YOUR RECORDS AirMax Breather ™ Name: ______________________________________________________________ School: _____________________________________________________________ School District: _______________________________________________________   School Address: ______________________________________________________ City: ______________________________ State: ____ Zip Code:  _______________   School Phone: _______________________ Email Address:  _______________________________________________________   Method of Payment (Please check only one): P.O. Number: _____________________________________________        Name to send invoice to: ___________________________________ Check Money Order Please make check or money order payable to Sage Dynamics. Ordered through (if applicable): __________________________________________ Quantity: __________ Price (each): $12.95 Subtotal: __________ Tax: __________ Texas residents only: include applicable sales tax (usually 8.25%).  If tax exempt, please include a tax exempt form. Shipping and Handling: __________ 1-15 units:    $3.00 each unit over 15 units:$15 flat fee Grand Total: __________ Please mail payment and order form to: Sage Dynamics 12436 FM 1960 W. #125 Houston, TX 77065   Please allow up to 4 weeks for delivery.