Marianna Industries, Inc
11222 “I” Street
Omaha, NE 68137
800-228-9060 Watts
800-762-4329 Fax
Rep Name MICHAEL WEINSTEIN
Date:___________
LEFT HANDED SCISSOR
Please send (__) of Kit #_21039_ in the amount of $460.22
shipping and handling
$15.00
$475.22
I understand that my order will take approximately 7-14 working days to receive.
Enclosed is a Certified Check, or Postal Money Order (No Personal Checks will be
accepted), Or Bill my VISA or MASTERCARD.
Name of Person on Card
Address of Card Holder___________________________________
City____________________ State_____________Zip__________
Phone# of card holder_____________________________________
M.C. or Vs #
_______________________
SECURITY CODE_____________
Expiration Date ____________
Signature of cardholder : ___________________________________
I understand that this purchase will be shipped directly to the school in the name of
kit owner. The billing on credit card will state Marianna Industries, Inc
Student Name
School Name OLIVER WOLCOTT REG.VO TECH
School Address 75 Oliver Street
City Torrington State
CT Zip 06790
Daytime Phone
I understand the school is NOT responsible for any transactions. I also understand that
any Shortages/Problems with the kit MUST be reported to Marianna’s School
Representative within 10 working days of receipt of kit.
Thank you,
Signature of Student (19+)
Signature of Parent/Guardian