Driver Safety Hammer...Seat Belt Cutter...AAA Emergency Flashlight

First Name (required)     Last Name (required)

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Daytime Telephone Number     Extension     (required)

Cell Phone (optional)    Evening Telephone Number (optional)

Quantity of Safety Hammers You are Ordering    x $10.00 = $ + $4.95 **Shipping and Handling.  **Freight Charge is for entire order!

Please provide Name, Shipping to Address, (no PO Boxes), credit card type (Visa or MasterCard), number, expiration date, zip code  and any other instructions in the following dialogue box below. If using a credit card, we will include your credit card receipt with your order.

I would like to be contacted for a PRIVATE GROUP(s) of Six people or more to take the Course at our Location or Yours.

You may fill out this form, submit it, print it and fax it to 516-377-0225

or

Mail this form with your payment to

Freeport Consulting Group, Inc. 

18 East Sunrise Highway, Freeport, NY  11520