Radon Testing Co.
815-397-2366

TomBrain1@aol.com

INVOICE PAGE
*To avoid delay in the forwarding the Radon test report, print and fill out the information below on the day of the test request and forward to the Radon Testing Co. 1657 Red Oak Lane Rockford, Il. 61107  or copy and attach to: TomBrain1@aol.com

MUST HAVE INFORMATION:

         Name, Print all.__________________________________________________________________________

         Address, Tested: _______________________________________________________________
        
                         City & Zip:____________________________________________________________

          Your Agent & Co._______________________________________________________________



*CREDIT CARD FORM: PRINT ALL

          TYPE OF CARD:  Visa _______ MC ______ Discover _________  American Ex ________

         Card No. ___ ___ ___ ___/___ ___ ___ ___/___ ___ ___ ___/___ ___ ___ ___
           
           Exp. Date___ ___/___ ___       Code on the Back _________

            Amount:___________

         Address on Card: _____________________________________________________________________

                      City & Zip:  ____________________________________________________________



*CHECK ENCLOSED _____ NO: ____________

             Amount: ___________


             Mail to:  Radon Testing Co.
                     1657 Red Oak Lane
                     Rockford, Il. 61107

              Phone: 815-397-2366
             Fax: 815-394-1611
             
              TomBrain1@aol.com

             Thank you, For Testing your home for Radon; to ensure a Safe & Healthy home.
             The Best of Health, Thomas Brain