Customer Information

	Ship Items To: CopierChip 1857 White Mtn Hwy North Conway, NH 03860

Company Name ______________________________
(current customers need only fill out company name )

Shipping Address _____________________________

_____________________________________________

City_________________________________________

State ______________________ Zip ______________

PO# _________________________________________

Contact Name _______________________________

Phone ______________________________________

Fax ________________________________________

Email Address _______________________________

Referred by? ________________________________

Total quantity of chips shipped: ____________

Please specify models and colors below.

Minolta models:

Minolta 1501-2001, Cyan_______ Magenta _______ Yellow _______ Black _______
Minolta 2002-3102, Cyan_______ Magenta _______ Yellow _______ Black _______
Konica Minolta C350, C351, C450, Cyan_______ Magenta _______ Yellow _______
Konica Minolta C350, Black _______ C351-C450, Black _______
Konica Minolta C250, C252, Cyan_______ Magenta _______ Yellow _______ Black _______
Konica Minolta C300, C352, Cyan_______ Magenta _______ Yellow _______ Black _______
Konica Minolta C451,C550,C650 Cyan_______ Magenta _______ Yellow _______ Black _______

Other models:

Kyocer Mita 1530, Cyan_______ Magenta _______ Yellow _______ Black _______
Kyocera Mita 2030-3130, Cyan_______ Magenta _______ Yellow _______ Black _______
Kyocera Mita 2230, Cyan_______ Magenta _______ Yellow _______ Black _______
Konica 8020-8031 , Cyan_______ Magenta _______ Yellow _______ Black _______
Imagistics, Cyan_______ Magenta _______ Yellow _______ Black _______

Thank you for your order!