Print and fill out this form, then mail or fax it to us using the information on our Contact page.
| Date:_____/______/______ | ||
| PAYMENT BY: | Order Number:________________ | |
| Check: _____ | Card Type:______________________ | Customer Number:________________ |
| Charge: _____ | Card or Account No:_____________________ | Direct Inquiries To:_________________ |
| Purchase Order:_____ | P.O. #: _________________ | Delivering Date Requested:__________________ |
| C.O.D.:_____ |
Payment Policy: 30 DAYS
| Stock No. | Unit/PKG | Description | QTY | Price/Unit | Total Amount |
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Bill To: _______________________________________ Address: ______________________________________ _____________________________________________ Ship To: _______________________________________Address: ______________________________________ _____________________________________________ Signature_______________________________________ |
Tax Rate:_____ |
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