Air Lift Retail Order Form

Retail Order Form

* Indicates Required Information

*An Airlift shipping manager will contact you via the phone number or email address provided below to define the payment arrangements.

*Ship To: (Street Address Required; No Post Office Boxes)

Recipient Name: (Last, First, MI)
Apt/Suite/Unit: (if applicable)
Street Address:
City:
State or Province (use 2-letter abbr.)
Zip or Postal Code:	-
Country:
*Daytime Telephone Number: (including area code)
E-mail Address:

Please send me the following Air Lift Product (s):

Qty:	Product:	Model No:	Price:
	Backpack for Liquid Oxygen	14	$72.00
	Backpack for Liquid Oxygen, Child	14-C	$72.00
	Backpack for HELiOS ^TM***	16	$55.00
	Backpack for M6, C/M9 and smaller cylinder	24	$55.00
	Backpack for M6, C/M9 and smaller cylinder, Child	24-C	$55.00
	Backpack for D Cylinder.	26	$55.00
	Fanny Pack for M6, C/M9 or smaller cylinder	46	$63.00
	Fanny Pack for A/B4 cylinder	48	$63.00
	Camera-Style Shoulder Bag for M6, C/M9 & B cylinder	49	$44.00
	Product Total		$

	**Shipping & Handling, UPS Ground		$8.50
	**Shipping & Handling, UPS Ground COD		$15.00

	Order Total		$
For shipments within the 48 contiguous States and Canada, only. For Alaska, Hawaii and other countries or for expedited shipments, please call Customer Service. * HELiOS^TM is a trademark of CAIRE, Inc.^TM Order will be confirmed by e-mail within one (1) business day of its receipt.


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