Order Form

Equipment and Supply Central
Toll Free:  800-352-0272    Fax Line:  800-353-3681 
PO Box 320155   Birmingham, Alabama 35232

 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____

On Account:                                          		 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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