​Mail-In/Fax Order Form

  Print this form out with the necessary information and send it to the address at the bottom or fax it to us at 330-533-6353.


FULL NAME:_______________________________________________________
TELEPHONE NUMBER_______________________________________________
SHIPPING ADDRESS________________________________________________
EMAIL ADDRESS___________________________________________________


YOUR ORDER:  



  MARK QUANTITY NEXT TO EACH ITEM:


     .5” PAIR OF SHOE INSERTS - ($10.50) ______________
  1.00” PAIR OF SHOE INSERTS - ($11.95) ______________
  1.25” PAIR OF SHOE INSERTS - ($13.75) ______________
  1.50” PAIR OF SHOE INSERTS - ($15.45) ______________
  1.75” PAIR OF SHOE INSERTS - ($17.95) ______________
  2.00” PAIR OF SHOE INSERTS - ($19.50) ______________
  2.25” PAIR OF SHOE INSERTS - ($21.50) ______________
  2.50” PAIR OF SHOE INSERTS - ($23.95) ______________
  3.00" PAIR OF SHOE INSERTS - ($29.95) ______________


If ordering (4) of each size deduct 18%, if ordering (8) of each size deduct 36% from
the individual pricing.


SAMPLE PACK #1 1”, 1.5”, 2” PAIRS ---------------------------------($29.95) ____________
​SAMPLE PACK #2 1”, 1.5”, 2”, 2.5” PAIR ----------------------------($48.50) ____________
SAMPLE PACK #3 1/2", 1 1/4", 1 3/4" PAIRS ---------------------($29.50) ____________
SAMPLE PACK #4 1/2", 1 1/4", 1 3/4" and 2 1/4" PAIRS-------($42.75) ____________
SAMPLE PACK #5 2 1/4" and 2 1/2" PAIRS------------------------- ($32.50) ____________
SAMPLE PACK #6 2 1/2" and 3" PAIRS-------------------------------($41.95) ____________
ULTIMATE SAMPLE PACK-------------------------------------------------($89.50) ____________

  SHIPPING AND HANDLING:


  - REGULAR FIRST CLASS MAIL ------------------------------ (ADD $6.95) ________

  - PRIORITY MAIL ------------------------------------------------------(ADD $11.95) ________

  - INTERNATIONAL SHIPPING (REST OF WORLD) ------(ADD $12.95) ________

AMOUNT OF US DOLLARS ENCLOSED---------------- $___________________

 CHECK OR MONEY ORDER TOTAL AMOUNT---------$____________________



VISA/MASTERCARD/DISCOVER:


ACCOUNT NUMBER ________________________________________________

THREE DIGIT CODE ____________

EXPIRATION DATE ____________

  NAME AND ADDRESS ON ACCOUNT IF DIFFERENT FROM ADDRESS ABOVE


  FULL NAME:          ______________________________________________________

  BILLING ADDRESS:______________________________________________________





  SEND PAYMENT TO:



  Canfield Plastics

  10670 Lisbon Road

  Canfield, OH 44406




​   FAX TO: 330-533-6353


Levitator Lifts  |  100% American Made Products!  |  Designed & Copyrighted by www.elegantwebstudio.com


Levitator Lifts are the Original Legitimate Height Increasing Shoe Insoles of the United States and the World.