Customer Information |
ph:
760.726.7717 | fax: 760.630.0722 e-mail:
Sylvieclat@aol.com Date:
__________/___________/__________ |
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| Name:______________________________________ | |||||
| Phone: _____________________________________ | |||||
| Address: ____________________________________ | |||||
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City: _______________________________________ |
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| State: _________ Zip: __________________ | |||||
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E-mail: ______________________________________ |
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Shipping
Information [Check if same as customer address: ________] |
Billing Information |
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Name:
_______________________________________ |
Name on card: ________________________ |
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| Phone: _______________________________________ | Card Type: _______________________ | ||||
| Address: _____________________________________ | Credit Card Number:_____________________________ | ||||
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City: ______________________________________ |
Exp. Date: ____________________________ |
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| State: _________ Zip: __________________ | |||||
Order Information:
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Quantity
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Stock Number
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Description
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Unit Price
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Amount
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Shipping:
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Please leave this area blank. |
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Please leave this area blank. Salesperson:_____________________________________________________ Customer Order No: ______________________________________________ Tax exemption number:
__________________________________________ |
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Total:
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