Ship To: Sold To:
Name   Name
Street   Street
City   City
State   State
Zip   Zip
Home Phone   Home Phone
Work Phone   Work Phone
Fax   Fax
EMail   EMail
Special Instructions
1. Whirlpool Tub Model No.
2. Tub Color
3. Jet Trim
4. Heat Retention Unit
5. Moodlight
6. Pillow
7. Waste and Overflow Kit
8. Tile Flange Kit
9. Tub Skirt
10. Access Panel Tub Skirt
11. Pump Upgrade
12. 50 Hz Pump
13. Faucet Set