EngineerSupply FAX or MAIL Order Form

FAX To: 888-938-1787
OR Mail To:
EngineerSupply
3300 Odd Fellows Rd.
PO Box 11765
Lynchburg, VA 24506

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 5.3% Sales Tax
or if tax exempt, FAX Tax Certificate or Contact Us with Order

  

Subtotal:

  

Shipping Method: 5-7 Business Day

  

Shipping $ Total:

  

ORDER GRAND TOTAL,  Including Tax and Shipping: