Fax Product Order Form Please Print

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Fax Product Order Form Please Print

FAX Product Order Form
Please print, fill out, and fax to 1-800-99FAXUV (800-993-2988) or (773) 880-6647.
(Note: $10 minimum on credit card orders, other orders $25 minimum)

Company:
Your Name:
Phone:
Fax:
Email:

		Account Information
		Do you have an account with us? yes no
		If yes: Account number: _________________
		PO number: ____________________
		If no, please choose one:
		Please send COD. (Not allowed for residential addresses)
		Please charge to my credit card. You should have my information on file.
		Please charge to my credit card.
		Credit card #:________________________________
		Credit Card type (circle one): Visa MasterCard American Express
		Name on Card: ______________________________
		Authorized Signature: _________________________
		Exp. date:____/____/____
		If American Express, please include the four-digit number on the right of card here: ________
		Credit Card Billing Address:


		Check here if you would like to keep your credit card information and signature on file for future orders.

		Billing Information
Bill To:
Billing Address:

City:
State/Province:
Postal Code:
Country:
Billing Phone:
		Is your ship-to location a business or residential address?
		Business Address
		Residential Address (No COD orders allowed)

		Shipping Information (if different than billing address)
Company:
Shipping Contact:
Shipping Address:

City:
State/Province:
Postal Code:
Country:
Shipping Phone:

Part Number	Quantity	Size	Description	Price/Each	Total