EngineerSupply FAX or MAIL Order Form |
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FAX To:
888-938-1787 |
TO ORDER: Complete all blanks, please write neatly, if not typing, and Fax or Mail it to us. We will email a confirmation. Remember to enclose your check or credit card information. |
BILLING INFO |
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Person Ordering: | First: | Last: | |||||
Company: | |||||||
Address: | |||||||
City: | State: | Zip: | |||||
Phone Number: | |||||||
E-Mail Address: | |||||||
SHIPPING INFO (Leave this area blank if same as billing info) |
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Name: | First: | Last: | |||||
Company: | |||||||
Address: (NO P.O. Box) | |||||||
City: | State: | Zip: | |||||
Phone Number: | |||||||
Notes: | |||||||
If paying
by credit card, please provide the information below: |
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Card Type: (Circle One) MasterCard Visa Discover Amex | |||||||
Card Number: |
CVV (3-digit code): | ||||||
Exp Date: (mm/yyyy) | |||||||
-----------------City, State, and Zip where credit card statement is mailed------------------- |
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City: | State: | Zip: | |||||
Please Note: The
billing address above is authorized by the cardholder
below. By signing, you understand and agree that we will process your order and place a charge to your credit card. Cardholder Signature:____________________________________________ Cardholder Name Printed:_________________________________________ Cardholder Phone: (______)____________________ |
PRODUCT SELECTIONS |
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Qty |
Product Code |
Description | Color/Option | Price Each | Subtotal |
Virginia
Customers Only: Please Add 5.3% Sales Tax |
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Subtotal: |
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Shipping Method: 5-7 Business Day |
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Shipping $ Total: |
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ORDER GRAND TOTAL, Including Tax and Shipping: |