PURCHASE ORDER #__________________

SHIP VIA (CIRCLE ONE) GROUND 3 DAY 2ND DAY NEXT DAY AIR SHIPPING TERMS: (CIRCLE ONE) PRE-PAID & COLLECT

I WOULD LIKE TO RECEIVE A FAX CONFIRMING OF THIS ORDER : YES NO 100% SATISFACTION GUARANTEE. THANK YOU FOR YOUR BUSINESS

CUSTOMER INFORMATION
ORDER PLACED BY:_______________________________
PHONE: ( ___ ) ______________ EXT:______ FAX: (___) _______________

PAYMENT & SHIPPING INFORMATION
BILL TO: CUSTOMER NAME:_______________________________

ADDRESS:_________________________________________________________________
CITY:_______________________________ STATE ________ ZIP______________

SHIP TO:________________________ CUSTOMER NAME_________________________

ADDRESS:_________________________________________________________________
CITY:_______________________________ STATE_________ ZIP_____________

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