EngineerSupply FAX or MAIL Order Form

FAX To: 888-938-1787
OR
Mail To:
EngineerSupply
21430 Timberlake Rd
Unit 349
Lynchburg, VA 24502

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

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)

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:
(If paying by check, please mail along with this completed form)

PAYMENT INFO

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-------------------

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

Qty

Product Code

Description Color/Option Price Each  Subtotal
           
           
           

Virginia Customers Only: Please Add 5.0% Sales Tax
or if tax exempt, FAX Tax Certificate or Contact Us with Order

 

Subtotal:

 

Shipping Method: (Circle One)
3-4 Business Day  OR   5-7 Business Day

 

Shipping $ Total:

 

ORDER GRAND TOTAL,  Including Tax and Shipping: