BatteryMart Order Form

Please note: Although it is most unlikely that you will experience any problems responding to this form, certain non-standard browsers will not respond properly. If you experience any difficulties, (or if you are not using a forms-capable browser) you may email your response to this form to: batteries@hearmn.com.

Fill-in the information required below.

Your Email Address:
Your Name:
Your Address:
City:
State:
Zip Code:
Phone #: (In case I need to reach you)

Battery size:
Number of boxes:
price per box = $27.50 Please enter your total ====$>

Enter any comments:

Method of payment:
Credit Card

I will call with credit card information (1-218-326-5986")
I will enter credit card information now

Card Type:
Credit Card Number :
Expiration Date :
Name as it Appears on Card :
Check

Make Check payable to:HEAR
Mail checks to:

HEAR
1275 SOUTH POKEGAMA AVE
Grand Rapids, MN 55744

Please allow 1 week from receipt of payment. I will notify when check is received.

This form will not inform you that the order was sent

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Copyright © Hearing Equipment and Repair Last Updated July 26 1999 by
Curt Larson
Curt@hearmn.com