Page 111 - Sensor-1 Big Catalog

Order Order Form Form Order Order Form Form How did you hear about us: ____________________________________________________________________
Purchase Order #: __________________________________ Company Name: Name: __________________________________ Customer Name: Name: ___________________________ ___________________________ Billing Address: ____________________________________________________________________________ City: ________________________ ________________________ ________________________ State: ________________________ ________________________ ________________________ Zip Code: ________________________ ________________________ ________________________ Phone: (______) (______) ________________ ________________ ________________ Fax: (______) (______) ________________ ________________ ________________ Email: ___________________________ Is Billing Address Address same as Shipping Address: Yes No
Shipping Address: ______________________________________________________________________________ City: ________________________ ________________________ ________________________ State: ________________________ ________________________ ________________________ Zip Code: ________________________ ________________________ ________________________ Phone: (______) (______) ________________ ________________ ________________ Fax: (______) (______) ________________ ________________ ________________ Email: ___________________________ Payment Method:    Check    Credit Card    Net Terms
Type of Credit Card:     MasterCard     Visa     Discover     Amex Credit Card # ______________________________ Expiration Date: ______________ ______________ ______________ Security Code: ________ ________ ________ ________ ________ Name as as it appears on card (Please Print): ________________________________________________________ Signature: ______________________________________________________________ Date: _______________ _______________ _______________ _______________ _______________ Qty
Price per Item
Price per Item
Discount (If Any)
CC Fee 3% Shipping TOTAL
Total Price Toll Free: 1-800-SENSOR-1 • • • 1-800-736-7671 • • • Phone: 1-785-937-4466 • • • Fax: 1-785-937-4386 111
Shipping Method: Part #   UPS   US MAIL Item
Description (Brief)
 3RD PARTY____________________________ Provide Shipper #