Page 99 - 2015 Sensor-1 Catalog
P. 99
Order Form
How did you hear about us: ____________________________________________________________________ Type of Order (Check One): oPersonal oOffice
Purchase Order #: __________________________________
Company Name: __________________________________ Customer Name: ___________________________ Shipping Address: ____________________________________________________________________________ City: ________________________ State: ________________________ Zip Code: ________________________ Phone: (______) ________________ Fax: (______) ________________ Email: ___________________________ Is Billing Address same as Shipping Address: oYes oNo
Billing Address: ______________________________________________________________________________ City: ________________________ State: ________________________ Zip Code: ________________________ Phone: (______) ________________ Fax: (______) ________________ Email: ___________________________ Payment Method: o Check o Credit Card o Sensor-1 Account
Type of Credit Card: o MasterCard o Visa o Discover
Credit Card # ______________________________ Expiration Date: ______________ Security Code: ________ Name as it appears on card (Please Print): ________________________________________________________ Signature: ______________________________________________________________ Date: _______________ Shipping Method: o UPS o US MAIL
Part #
Item Description (Brief)
Qty
Price per Item
Total Price
Price per Item
Discount (If Any)
C.O.D. ($8.00)
Shipping
TOTAL
Toll Free: 1-800-SENSOR-1 1-800-736-7671 Phone: 1-785-937-4466 Fax: 1-785-937-4386 -99
