Printable Order Form

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Print this form to fax your request 24 hours a day - 603.437.7073
Please enter information completely. Thank you for the opportunity to be of service

First Name: ____________________	MI: _____	Last Name: ____________________________
Street Address: (Required for Service): ________________________________________________________
Apt/Suite: (Required for Service): ________________________________________________________
City: ____________________	State: _____	Zip Code: ____________________________

Please enter your comments or tell us about the problem:

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I'd like to know more about... (Select one)
New Construction	Remodeling
General Repairs	Pools & Spas
Fire Alarms and Security Systems	Telephone Wiring
Telephone Systems & Repairs	Commercial Telephone Systems
Computer/Data Wiring	Energy Conservation
Emergency Power -Generators/Semi-Automatic Transfer Switches

Please fax to: 603.437.7073

Mail to: Custom Design Electric

Corporate Offices

516 Old Mammoth Rd. Londonderry, NH 03053

(603) 437-8059 fax: (603) 437-7073

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