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D & B Safety Co., Inc.                                   Phone: 785-285-1653
1114 Wyoming St.                                         Fax:   785-284-3227
Sabetha, KS 66534-2516

SOLD TO:                                 SHIP TO: (If not the same)

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Name                                     Name

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Address                                  Address

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City, State, Zip                         City, State, Zip

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Phone Number                             Please specify shipping date


|                                              |     |    P  R  I  C  E    |
| Item                                         | QTY |   Each   |  Total   |
|----------------------------------------------+-----+----------+----------|
|                                              |     |          |          |
|----------------------------------------------+-----+----------+----------|
|                                              |     |          |          |
|----------------------------------------------+-----+----------+----------|
|                                              |     |          |          |
|----------------------------------------------+-----+----------+----------|
|                                              |     |          |          |
|----------------------------------------------+-----+----------+----------|
|                                              |     |          |          |
|----------------------------------------------+-----+----------+----------|
|                                              |     |          |          |
----------------------------------------------------------------+----------|
 Packaging and Shipping Charges:                      SUB TOTAL |          |
                                                                |----------|
 Up to $24.99       - $5.95        For IN orders, add sales tax |          |
 $24.99 to $49.99   - $8.95                                     |----------|
 $50.00 to $84.99   - $9.95                 Shipping & Handling |          |
 $85.00 to $99.99   -$12.95                                     |----------|
 $100.00 to $200.00 -$14.95                               Total |          |
 Over $200.00        $16.95                                     ------------
 In Continental USA
 All orders under 20 lbs. shipped priority mail.
Please inquire for other shipping
PAYMENT METHOD: 
( ) Check Enclosed, Make check payable to "D & B Safety Co. Inc.".

( ) MasterCard or Visa

    Card Number: ______________________________  Expiration Date: __________  
		

    Signature:___________________________________