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Assistive Technology Solutions

Providing Plans for Do-It-Yourself Devices
 to Assist Persons with Disabilities


Print this form, fill out, and return to AT Solutions

 

S
O
L
D

T
O
Name _________________________________________________

Street Address __________________________________________

City ____________________________  State ____ Zip __________


S
H
I
P

T
O
Name __________________________________________________

Street Address __________________________________________

City ____________________________  State ____ Zip __________


Quantity Plan Number Description Plan Price Total
         
         
         
         
SEND TO:
Assistive Technology Solutions
PO Box 3071
Burlington, VT 05401

Total
Amount
Due

 
 

Make checks payable to:
 Assistive Technology Solutions

 
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