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Hearing Solutions LLC
123 Saratoga Road, Socha Plaza
Scotia, NY 12302

Please send me the following:

Quantity
Description
Price
Total
_____
Pack of (8) batteries
$7.50
=
$_______
_____
Pack of (4) batteries
$4.25
=
$_______
_____
Box of (40) batteries
$35.00
=
$_______

Battery Type (circle one):  A-675   A-312   A-13   A-10   A-5


Mailing Information:

Name _________________________________________________________

Address _______________________________________________________

City _______________________________ State _______ Zip ____________


Payment Information (send payment with order form):

___ Personal Check___ Money Order___ Credit Card

Credit Card Information:

___ MasterCard___ Visa___ Discover___ American Express

Name of credit card holder: _________________________________________________

Credit card account #: _____________________________________ Exp Date: _______

Signature: ______________________________________________________________

Allow 1-2 weeks for delivery. Free postage anywhere in the United States.
Thank you for your order!