| CUSTOMER
INFORMATION |
NAME |
| BUSINESS |
| ADDRESS |
| CITY,
STATE & ZIP/POSTAL CODE |
| DAY PHONE
( ) _______ - __________
EVENING
PHONE (
) _______ - __________ |
| EMAIL ADDRESS ______________________________ @
______________________________ |
| DELIVERY
ADDRESS: [ ] RESIDENCE
[ ] BUSINESS [ ]
P.O. BOX |
| PAYMENT
INFORMATION |
| CREDIT CARD #
__ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ |
| AMERICAN
EXPRESS # NOTE:
We do NOT currently accept American Express cards |
| EXPIRATION DATE
__ __ / __ __ |
| NAME
EXACTLY AS IT APPEARS ON CREDIT CARD
_________________________ |
| SECURITY
CODE ___ ___ ___ SEE INSTRUCTIONS BELOW |
| CUSTOMER
SERVICE TELEPHONE ON BACK OF CARD (______)______-_________ |
[ ] CASHIER CHECK / MONEY ORDER ENCLOSED [ ]
BANK WIRE TRANSFER SENT |
| EQUIPMENT
ORDER |
| ITEM # |
DESCRIPTION |
QTY |
COST |
TOTAL |
| |
|
|
$ |
$ |
| |
|
|
$ |
$ |
| |
|
|
$ |
$ |
| |
|
|
$ |
$ |
SELECT
SHIPPING METHOD |
| [ ]
$15.00 FedEx Ground [ ] FedEx
3-Day [ ]
FedEx 2-Day [ ]
FedEx Overnight |
| [ ] USPS Priority
Mail (2 - 3 days) [ ]
USPS Express Mail (1 - 2 days) |
SHIPPING,
TAX & TOTALS |
| SUB-TOTAL |
$ |
| (See S & H Information Below)
SHIPPING |
$ |
|
NEVADA
RESIDENTS ADD SALES TAX |
$ |
| TOTAL |
$ |
| BY SIGNATURE BELOW CUSTOMER ACCEPTS ALL
TERMS &
CONDITIONS |
SIGNATURE (Required): |