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Fax / Phone Order Form

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Print and fill out this form and fax or call in your order to one of the following locations:

Fremont

Columbus

Grand Island

ph  (402) 721-6436

ph  (800) 658-4441

fax (402) 721-3517

ph  (402) 564-1309

ph  (800) 658-4478

fax (402) 563-1939

ph  (308) 384-0680

ph  (800) 652-9409

fax (308) 384-0681

 

 

Ordered by: Ship To:

Company:__________________________________

Address:  __________________________________

Attention of: ________________________________

City:  _________________  ST ____  Zip_________

Your Name: ________________________________

Title:  _______________________  Date: ________

Phone:  (         ) ______________  P.O. # _______

Company:__________________________________

Address:  __________________________________

City:  _________________  ST ____  Zip_________

Your Account # _____________ (we have it if you don't)

Special Instructions:  _________________________

___________________________________________

___________________________________________

QTY Stock Number Description Unit Price Total Price