Fax in and Mail in Order Form

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 Call us with Questions 877-900-9499

How to order using the order form:

#1  Fill in this order form and FAX it to us at 800-515-1618
#2  Mail in this order form with payment to:

Make Checks Payable to:
A1 Specialties, Inc.
PO Box 171213
Memphis, TN 38187

Please select

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 Roof Raider (Small Kit) Up to 1000 sq ft home $29.95 plus $7.95 shipping Total: $37.90

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 Roof Raider (Medium Kit) Up to 3000 sq ft home $49.95 plus $7.95 shipping Total: $57.90
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 Roof Raider (Large Kit) Up to 5000 sq ft home $79.95 plus $7.95 shipping Total: $87.90

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 Roof Raider (Commerical bulk) 40 lb Pail $224.95 plus $30.90 shipping Total: $255.80

 

Your Information

First Name_________________________________Last Name ______________________________________

Shipping Address___________________________________________________________________________

City ____________________________________________ State ____________ Zip_____________________

Telephone (__________) ___________________________ Email____________________________________
MUST HAVE VALID CONTACT INFORMATION AND PHONE NUMBER
  
VISA  MASTERCARD    AMEX    DISCOVER     MONEY ORDER/CHECK  
(Please Circle One)

Card # ________________________________________________________________

Exp._______________________

Name That Appears on Card:

  __________________________________________________________________________

*ATTN: Check Customers:
*All check orders are held for 10 days before product ships. If you are paying with a check please specify on the check what product you are purchasing