Order Form

PO #
(*Required Field)
Ship To Address:
(Street address only, no P.O. Boxes)
Phone: (Very important)
Bill To Address:
(Street address only, no P.O. Boxes)
Phone:
Fax:
Email:*
MATERIAL SALES
(SUPPLIES)
QTY ITEM # / DESCRIPTION TOTAL VALUE
Ship Via:
Preferred Motor Carrier:
DISTRIBUTION ORDERS
(SHIPMENTS)
QTY ITEM # / DESCRIPTION TOTAL VALUE
Merchandise COD:

 Yes  No

If yes, enter amount: $
Party to Pay for Shipping: *

 Shipper Consignee

Preferred Motor Carrier:

Party to Pay for Packing: *

 Shipper  Consignee

If Other: (3rd Party Billing)
Name:
Street Address:
Phone: (Very important)
PAYMENT WILL BE MADE BY: *

 Established Corporate Account  Credit Card

VISA, MASTERCARD, AMERICAN EXPRESS ACCEPTED.
FAX CREDIT CARD INFORMATION TO (336) 885-4397
SORRY, NO DEBIT CARDS ACCEPTED

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