Page 105 - 2017 Sensor-1 Catalog
P. 105
Order Form
How did you hear about us: ____________________________________________________________________ Purchase Order #: __________________________________
Company Name: __________________________________ Customer Name: ___________________________ Shipping Address: ____________________________________________________________________________ City: ________________________ State: ________________________ Zip Code: ________________________ Phone: (______) ________________ Fax: (______) ________________ Email: ___________________________ Is Billing Address same as Shipping Address: Yes No
Billing Address: ______________________________________________________________________________ City: ________________________ State: ________________________ Zip Code: ________________________ Phone: (______) ________________ Fax: (______) ________________ Email: ___________________________ Payment Method: Check Credit Card Sensor-1 Account PayPal Wire Transfer
Type of Credit Card: MasterCard Visa Discover American Express
Credit Card # ______________________________ Expiration Date: ______________ Security Code: ________ Name as it appears on card (Please Print): ________________________________________________________
Signature: ______________________________________________________________ Date: _______________ Shipping Method: UPS US MAIL
Part #
Item Description (Brief)
Qty
Price per Item Total Price
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 -105
