Fax or Mail Order Form
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Fax To: 1-314-961-7245

This form may be used to order using fax or regular mail to:
Midwest Divers Supply
Attn: Order Department
8121 Big Bend Blvd
St. Louis, MO 63119

Bill To:		Ship To If Different:
Name:		Name:
Address:		Address:
Line 2:		Line 2:
City:		City:
State:	Zip:	State:	Zip:
Phone:		Phone:
e-mail:		e-mail:

Item Name or #	Size	Color	Item Description + Diver #	Qty	Price	Total
Sub Total
Shipping Method: UPS Ground - US Postal Service Shipping Charges
Total

Method of Payment

Visa

Mastercard

American Express

Optima

Discover

Credit Card Number

-

-

-

Expiration Date:

Signature:

-

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Diver sex

Height

Weight

Pants size waist + legnth

Chest / Jacket

shoe

#1 Male / Female

#2 Male / Female

#3 Male / Female