Ship To:
Company Name:_______________________________________________ Customer Code__________
Contact Name:______________________________________________________________________
Address:__________________________________________________________________________
City:_____________________________________ Province/State____________________
Postal/Zip________________ Country______________________
Telephone:(_______)_______________________ Fax number:(_______)______________________
E-Mail:______________________________________ P.O.Number:______________________________
Quantity |
Code Number & Description |
Price Each |
Total |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| __________ | ____________________________________________ | $_________ | $______________ |
| Subtotal | $______________ | ||
| Terms Of Payment: (tick one) | Shipping | $__see_below___ | |
| VISA_____, MC_____, AMEX_____, On Account_____(Established Approved Customers Only) |
Total | $___.T.B.A.___ |
Credit Card #:_______________________________________________
Expiry Date:_______________
Signature: ______________________________________________ all orders must be signed.