Asymmetric Order Form

Asymmetric
6716 Candy Lane
Vermilion, OH 44089-3402

Please make your check or money order (or international money order in U.S. funds for non U.S. orders) payable to "Asymmetric" and mail to the above address along with this order form. Please allow three weeks for delivery.

(Optional)

Name:________________________________________
Phone:________________________________________
Email:________________________________________
Address:______________________________________
_____________________________________________
_____________________________________________
City:_________________________________________
*County (Ohio Residents Only):_______________________________________*
State:_______________	Zip Code:________________
Country:______________________________________

Please choose your model and quantity:
QUANTITY	MODEL	PRICE EACH	TOTAL
_____	Lead 342M	$78.00	___________
_____	Lead 342	$78.00	___________
_____	Opera 545	$78.00	___________
_____	3C+544	$78.00	___________
_____	POET	$78.00	___________
_____	VIRTUOSO	$78.00	___________
		SUBTOTAL	___________
Shipping, Handling, & Insurance US Customers: Please add $5.00 USD for the first mouthpiece plus $3.00 USD for each additional mouthpiece. Canadian Customers: Please add $12.00 USD for the first mouthpiece plus $7.00 USD for each additional mouthpiece. All Other Foreign Customers: Please add $15.00 USD for the first mouthpiece plus $10.00 USD for each additional mouthpiece.		SHIPPING	___________
Sales Tax: Ohio residents please add 6.75% of the subtotal.		SALES TAX	___________
		TOTAL	___________
RETURN POLICY Mouthpiece(s) may be returned in salable condition, subject to authorization, within 2 weeks. There is a $5.00 restocking and sterilization fee on all returns. Please call (440) 967-1470 for authorization before returning.