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ORDER REQUEST FORM


SOLD TO:

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(if different from "sold to")

P.O. Number (If applicable)
Company name:
Buyer's Name / Title: *
Street Address: *
City: *
State: *
Zip: *
Phone: *
Fax:
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Company name
Contact / Title *
Street Address *
City *
State *
Zip *
Phone *
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* Please provide an e-mail address to receive order confirmations,
updates and tracking notifications.
ORDER INFORMATION:

Qty: *

Item Code: *

Item / Product Description: *

Unit Price: * Total Cost: *

* Please ensure that the fields marked in red * are completed before submitting your request.
* Sales Tax - Orders shipped to addresses in California also pay an additional sales tax of 8.75%. If your business is tax exempt, please fax your California Non-Taxable Transaction Certificate to 800.753.0856.
* All orders ship via UPS Ground unless otherwise requested. For shipping charges and return policy read Shipping & Delivery Information. If an order is to be shipped via air (Next Day, 2nd Day, 3rd Day) or internationally (including Canada) you must call 800.753.9688 to make arrangements prior placing the order online.

Subtotal:
Tax:
Shipping:
Total:
METHOD OF PAYMENT:   BILLING ADDRESS:

Same as "sold to"

Credit Card type: *
Credit Card Number: * - - -
Expiration Date (mm/yy): *
Security Number (CVV2): *
Cardholder's Name: *
Company name
Street Address: *
City: *
State: *
Zip: *
Phone: *

Comments / Requests:

 

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