Please print this out and mail it with payment to us at:   
Providence Spillproof
P.O. Box 40672
Providence, RI 02940
or Fax it with credit card information to us at:  (401) 273 2601

Ship To:
NAME: ___________________________________________________________
ADDRESS:________________________________________________________
CITY: _____________________ STATE: ______ ZIP:_____________________
PHONE:____________________EMAIL ADDRESS: _____________________

Bill To:    __ Same as Above
NAME:__________________________________________________________
ADDRESS:_______________________________________________________
CITY: ______________________ STATE: _______ ZIP: _________________

__ Enclosed is my check payable to Providence Spillproof Container
Charge to:    __VISA, __MASTERCARD,
CARD NUMBER:_______________________________________________
EXPIRATION DATE: ________SIGNATURE_______________________

NAME OF ITEM QTY PRICE
EACH
TOTAL
PRICE
       
       
       

MERCHANDISE TOTAL:

 

SHIPPING CHARGE :

8.00

TOTAL AMOUNT DUE:

 
URSEC Urinal URSEC $45
Female URSEC $52

Please make checks payable to: Providence Spillproof Container
(888) 843-5287

Special Notes: