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On-Line Order Form
To order, please fill in the information below.
The ** indicates information that must be provided to properly process your order.
If you have any questions, please do not
hesitate to inquire through
email
or call us direct at the above number.
Remember do NOT use the
ENTER KEY
on this page. (Tab Key or Mouse only)
#1: Contact Information
P.O. #
Date:
Account #:
Quote #:
Contact Name:
Contact Phone:
Contact Fax:
BILL TO :
Company/Name
:
**
Address:
**
City:
**
State/Prov.:
**
Zip/Postal:
Country:
Phone:
**
Email:
**
SHIP TO:
(if different)
Company/Name
:
Address:
City:
State/Prov.:
Zip/Postal:
Country:
Phone:
Email:
#2:
Product Lines
Nightingale Brass 'n Color Table & Floor
* Models that include night light and receptacle.
** Alzheimers style with
night light, guard diffuser, perma-mount and rocker switch.
Model:
Select
343 (Qty 1-5) =$204.10
343 (Qty 6-24) =$186.05
343 (Qty 25+ =$167.44
345* (Qty 1-5) =$218.65
345* (Qty 6-24) =$198.77
345* (Qty 25+ =$178.89
346** (Qty 1-5)=$258.39
346** (Qty 6-24=$234.90
346** (Qty 25+)=$211.41
347 (Qty 1-5) =$212.32
347 (Qty 6-24) =$193.02
347 (Qty 25+) =$173.72
743 (Qty 1-5) =$252.23
743 (Qty 6-24) =$229.30
743 (Qty 25+) =$206.37
745* (Qty 1-5) =$266.22
745* (Qty 6-24) =$242.02
745* (Qty 25+) =$217.82
Shade:
Select
DuraLast
PolyLast
PolyLast II
Coolie
Drum
Finish:
Select
White
Almond
Ebony
Mauve
Taupe
English Bronze
Forest Green
Wedgewood Blue
Burgundy
Midnight Blue
Accents:
Select
Bright Brass
Brushed Brass
Bright Chrome
Brushed Chrome
Options:
Custom Finish=$350/25+ lot
Perma-Mount=$7.61
"Snap-in" Energy-Saving I=$39.43
Electrical Outlet=$5.55
Night Light=$8.47
"Twist-Loc" Energy-Saving I=$8.25
Guard Diffuser w/PolyLast Shade=$36.38
Hospital Grade Wiring=$17.60
Quantity:
Base Price Total Cost:
Nightingale Brass 'n Color SpaceSaver 535
Model:
Select
535* (Qty 1-5) =$229.07
535* (Qty 6-24) =$208.25
535* (Qty 25+) =$187.42
Shade:
Select
DuraLast
PolyLast
PolyLast II
Coolie
Drum
Finish:
Select
White
Almond
Ebony
Mauve
Taupe
English Bronze
Forest Green
Wedgewood Blue
Burgundy
Midnight Blue
Options:
Custom Finish=$350/25+ lot
"Snap-in" Energy-Saving I=$39.43
Night Light=$8.47
"Twist-Loc" Energy-Saving I=$8.25
Guard Diffuser w/PolyLast Shade=$36.38
Hospital Grade Wiring=$17.60
Quantity:
Base Price Total Cost:
Nightingale WallMount Swing Arm
Model:
Select
637 (Qty 1-5)=$179.10
637 (Qty 6-24)=$162.82
637 (Qty 25+)=$146.54
638 (Qty 1-5)=$163.73
638 (Qty 6-24)=$148.85
638 (Qty 25+)=$133.96
639 (Qty 1-5)=$324.41
639 (Qty 6-24)=$294.92
639 (Qty 25+)=$265.43
Shade:
Select
PolyLast
PolyLast II
Finish:
Select
White
Almond
Ebony
Mauve
Taupe
English Bronze
Forest Green
Wedgewood Blue
Burgundy
Midnight Blue
Options:
Custom Finish=$350/25+ lot
"Pin up" Standard=$27.91
"Pin up" Hospital=$31.54
Pull Chain Switch=$24.25
Electrical Outlet=$9.70
Night Light=$18.20
"Snap-In" Energy-Saving Package I=$39.43
"Twist-Loc" Energy-Saving Package I=$8.25
PolyLast Shade & Brass Accents standard with Model 637.
Smaller PolyLast II shade standard on Models 638 & 639
Quantity:
Base Price Total Cost:
Nightingale PolyLamp 350
Model:
Select
350 (Qty 1-5) =$150.28
350 (Qty 6-24) =$136.62
350 (Qty 25+) =$122.96
Shade:
Select
PolyLast
Finish:
Select
Almond
Putty (light gray)
Mauve
Forest Green
Wedgewood Blue
Burgundy
Options:
Guard Diffuser w/PolyLast Shade=$36.38
"Snap-in" Energy-Saving I=$39.43
Hospital Grade Wiring=$17.60
"Twist-Loc" Energy-Saving I=$8.25
Quantity:
Base Price Total Cost:
Nightingale Heavy-Duty Table & Floor
Model:
Select
326 (Qty 1-5) =$113.35
326 (Qty 6-24) =$103.05
326 (Qty 25+) =$92.74
335 (Qty 1-5) =$120.36
335 (Qty 6-24) =$109.42
335 (Qty 25+) =$98.48
335-CP (Qty 1-5)=$136.267
335-CP (Qty 6-24)=$123.87
335-CP (Qty 25+)=$111.48
453 (Qty 1-5) =$145.09
453 (Qty 6-24) =$131.90
453 (Qty 25+) =$118.714
453-CP (Qty 1-5) =$176.90
453-CP (Qty 6-24) =$160.82
453-CP (Qty 25+) =$144.74
Shade:
Select
DuraLast
DuraLast II
PolyLast
PolyLast II
Coolie
Finish:
Select
White
Almond
Ebony
Mauve
Taupe
English Bronze
Forest Green
Wedgewood Blue
Burgundy
Midnight Blue
Options:
Custom Finish=$350/25+ lot
Perma-Mount=$7.61
Hospital Grade Wiring=$17.60
"Twist-Loc" Energy-Saving I=$8.25
Quantity:
Base Price Total Cost:
Nightingale Studylamp
Model:
Select
336 (Qty 1-5) =$116.76
336 (Qty 6-24) =$106.15
336 (Qty 25+) =$95.53
366 (Qty 1-5) =$128.45
366 (Qty 6-24) =$116.77
366 (Qty 25+) =$105.09
Shade:
Select
PolyLast
PolyLast II
Options:
"Twist-Loc" Energy-Saving I=$8.25
Quantity:
Base Price Total Cost:
Nightingale Lamp Shades
Institutional- Grade:
Enter Quantity to order in appropriate quantity and price box
Part #
Description
Qty 1-5
$40.15
Qty 6-24
$36.50
Qty 25+
$32.85
#14218
DuraLast Shade, 6.5"x14"x 6.5"
#14063
DuraLast Shade, 8"x16"x 7.5"
#13794
PolyLast II Shade, 5"x11"x 9.75"
#11750
PolyLast Shade, 7"x15"x 10"
Commercial - Grade:
Enter Quantity to order in appropriate quantity and price box
Part #
Description
Qty 1-5
$21.03
Qty 6-24
$19.12
Qty 25+
$17.21
#10128
Trilam Coolie-Shaped Shade, 5"x19"x8"
#10077
Trilam Coolie-Shaped Shade, 6"x16"x7"
#10174
Trilam Drum-Shaped Trilam Shade, 13"x15"x12"
Base Price Total Cost:
#3:
Payment Information
Payment in $U.S. Dollars.
Note:
Sales tax will be charged to Wisconsin Buyer without a tax exempt form on fill at our corporate offices.
Open account, with approved credit!
MC
Visa
AM.EXPRESS Name on card:
Card #:
Please call with card Number
#4:
Shipping Information
Please send products via:
Select
UPS- Reg. Ground
Truck
Other(see below)
Your UPS #:
If other please state:
Additional Information to assist us in filling your order:
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Web Centers of America, Inc.
