1.) Print and fill out this form
2.) If you are using a credit card, fax the form to: 480-461-5187
3.) If you are using a check, mail the form to: Arizona AFO, Inc.: 1611 E. Main Street, Mesa, AZ 85203

Print or Type Clearly

Name:_________________________________________________________________

Company:______________________________________________________________

Title:__________________________________________________________________

Address:_______________________________________________________________

City and State:__________________________________________________________

Zip code:_________________ Country:______________________________________

Phone:_______________________________ Fax:_____________________________

Email: (case sensitive) ___________________________________________________

Visa/MC No:_____________________________Exp Date:_______________________

Name on Card:___________________________Amount (US): $__________________

PACKAGING INFORMATION: Socks are individually wrapped in foil pouch. There are 10 socks per box. Each box also includes 10 plastic baggies and instructional brochure. For the "Regular 17" Sock" there are 10 boxes (100 socks) per case. For the 'AFO" sock (30" length) there are 6 boxes (60 socks) per case. Ankle sock box includes one cutting strip and channel tube.

Questions, please call....or email us....Thank You.

Arizona AFO, Inc.
1611 E. Main Street
Mesa, Arizona 85203
Phone: 1-480-461-1940
Toll Free: 1-877-780-8382
Fax: 1-480-461-5187
don@arizonaafo.com