Beta Brite Accessories Order Form

Customer E-Mail

Important: A valid e-mail address is required to order online. If you do not have an email address you can place your order by phone Monday through Friday from 8 am to 5 pm EST by calling 800-341-6397.
E-Mail:*

Allow 24 hours for shipment processing (Monday through Friday). Your invoice / receipt will be attached to your shipment packaging. A physical address is required for shipping via UPS. If you need to place an order for delivery to a mail-stop or PO Box address please call 800-341-6397.

Beta Brite Classic and Prism Accessory Items
Item	Product Selection	Qty	Total
Remote Control
Power Supplies
Cables
Software
Sub-Total:
Shipping & Handling:*
Grand Total:
Billing Information
First Name:*			Same name as on your card
Middle Initial:
Last Name:*
Address Line 1:*
Address Line 2:			Apt. or Suite No.
City:*
State:*
Postal Code:*
Phone:
Shipping Information
Same as billing info:	Yes No
First Name:*
Middle Initial:
Last Name:*
Address Line 1:*
Address Line 2:
City:*
State:*
Postal Code:*
Purchase Order
Payment Information
Card Number:*			No dashes or spaces please
Expiration Month:*			From your card
Expiration Year:*			From your card
Card Brand:*
CVV
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