FAX OR MAIL
To order by Fax or Mail print out the completed form and send to us with check or payment info.
BILL TO:
*Company
*Contact
*Address
*City
*State *Zip 
*Phone  Fax 
*E-mail
SHIP TO: (if different from billing address)
Company
Contact
Address
City
State Zip 
Phone  Fax 
E-mail
Qty Part# Description Each Total
$
$
$
Notes:
PO#  Mark shipment: 
*SALES TAX is due on shipments to Calif destinations unless for resale.
If so, enter Ca Resale # 
PAYMENT METHOD: Credit Card Fax/Mail only: Check or Money Order Wire Transfer
Note: To apply for Net 30 day terms, please attach credit references (Fax / Mail only)
*Card No  *Expiration Mo/Yr  / 
*Billing Zip  *Billing Phone# 
Signature (Fax/Mail)
Total
Sales Tax *see note
Sub Total
Shipping Pre-Pay and Add**
Total

** Please call for shipping quote if required