Equipment and
Supply Central

Toll Free:  800-352-0272    Fax Line:  800-353-3681
 
PO Box 320155   Birmingham, Alabama 35222

              Order Form

Date:

   Sold To:
Contact Name:                                        
Company:                                                
Mailing Address:                                      
City:                                State:             
 Zip Code:                            

Phone:                                                             
Fax:                                                                   
E-mail:                                                               

          Ship To:   (if different than sold to)
Company:                                                       
Shipping Address:                                           
City:                                  
State:                   Zip Code:                           
Mark Order:                                          
Attention:                                                          
Specify Type of Payment:
Credit Card

Type of Credit Card:                              
Credit Card No:                                      
Expiration Date:                                      
               
CVV # :               
Name On Acct:
                                                
Shipping Information:
Ship Via:   (Circle or Mark one)
UPS -:                      Standard Ground:            
Next Day                                                  

Freight Line:                                              
Collect: (Specify freight line)                      
Prepaid and add/3rd Party:                        
Quantity Part Number

Description/color

Price ea $ Price Ext $
         
         
         
         
         
         
         
         
         

This form is provided to aid  in clarifying orders, and requests, it's certainly not mandatory to use.  Simply include the same information which might be pertinent.

                             Total Materials..................   $
                                            Freight    $
                                            Tax (If applicable)    
                                            Total.................   $


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