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Ordered By/Bill To:
Name:____________________________________
Company Name:____________________________
Acct#:___________________________________
Street Address:____________________________
City:______________State:_______Zip:________
Telephone:________________________________

Deliver To:
Name:____________________________________
Company Name:____________________________
Street Address:____________________________
City:______________State:_______Zip:________
Telephone:________________________________

Special Instructions:__________________________________________________________
________________________________________________________________________

Item Number

Description

Color

Unit

Price

Qty.

Amount

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Merchandise Total   

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Postage and Handling free if in delivery area, otherwise shipping charges will be added (same day delivery available on local orders received by 3pm)

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Applicable Sates Tax_____% 

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Total   

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Payment Method: __Visa    __Mastercard  __AMEX  __Discover  #___________________ Exp. Date______
___Charge to Account #_____________               ___C.O.D.