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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 difuser, perma-mount and rocker switch.
 ***   Models that include Dimming Switch.
Model:  Shade: Finish:
Options: 
Custom Finish=$150 lot Perma-Mount=$7.61 Energy-Saving I=$39.43
Electrical Outlet=$5.55
 Night Light=$7.32 Hospital Grade Wiring=$17.60
Wire Guard w/DuraLast Shade=$22.32  Guard Diffuser w/PolyLast Shade=$36.38
Quantity:    Base Price Total Cost:
Nightingale Brass 'n Color SpaceSaver 535
Model:  Shade: Finish:
Options:
Custom Finish=$175.00 lot Energy-Saving I=$39.43 Guard=$22.32
Night Light=$8.47 Hospital Grade Wiring=$17.60  
Wire Guard w/DuraLast Shade=$22.32  Guard Diffuser w/PolyLast Shade=$36.38
Quantity: Base Price Total Cost:
Nightingale WallMount Swing Arm
Model:  Shade:  Finish: 
Options:  
Custom Finish=$175.00 lot "Pin up" Standard=$27.91 "Pin up" Hospital=$31.54
Pull Chain Switch=$24.25 Electrical Outlet=$9.70 Night Light=$18.20
Energy-Saving Package I=$39.43
   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:  Shade:  Finish: 
Options:
Guard Diffuser w/PolyLast Shade=$36.38
Hospital Grade Wiring=$17.60 Energy-Saving Package I=$39.43
Quantity: Base Price Total Cost:
Nightingale Heavy-Duty Table & Floor
Model:  Shade:  Finish: 
Options:
Custom Finish=$150.00 lot Perma-Mount=$6.57 Hospital Grade Wiring=$17.60
Table Tray (Model 453 Only)=$31.50    Energy Saving Package II=$19.30
Quantity: Base Price Total Cost:
Nightingale Studylamp
Model:    Shade: 
Options: Energy-Saving Package 1=$34.12
  
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"
   
   
Quantity: 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!
Cash in Advance
MC  Visa  AM.EXPRESS  Name on card:
Card #: Please call with card Number
#4: Shipping Information
Please send products via:
Your UPS #:
Your Fedex #:
If other please state:

Additional Information to assist us in filling your order:

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