HOME ACCESS EQUIPMENT ORDER FORM HH 0 M F (Our Mission is to help people ive safely and independently wherever ACCESS SOLUTIONS they choose to call home, ‘Ask about our other services. Opening Doors of Opportunity q& Buy, Build, Sell, Oo Remodel [To Order: Home Access Solutions 7914 W Dodge Rd #326 Name: Omaha NE 68114 Address: Phone: 402-291-9514 Fax: 402-291-4202 Phone Item # Quantity Description ‘S Each Total Shipping & Delivery Charges Up to $15.00 15.01 - 25.00 25.01 - $0.00 50.01 - 75.00 75.01 - 100,00 100,01 - 150,00 - 150,01 - 200.00 - 200,01 - 300,00 ~ 18.50 cover $300 determined per order Merchandise Subtotal Discount - Enter code or type Shipping & Delivery Charge - Based On Merchandise Subtotal Subsotal Nebraska & lowa State and Local Sales Tax on Subtotal Order Total Cash Check Visa Mastercard Name on Card Card Number Expiration Date Security Code (on back of card): * Prices Subject To Change Without Notice * The right equipment can help you achieve independence and safety at home. Let us know if you need something you didn't see in this brochure. We also have licensed Occupational Therapists and Certified Aging-In-Place Specialists available to help you determine the correct equipment and/or to provide training in the privacy of your home within Greater Omaha, NE and Couneil Bluffs, IA areas. Thanks for your business!