Once this form is completed, please FAX it to
our
ORDER ENTRY DEPT. at
201-489-6650.
A confirmation will be forwarded to
you the same business day it is received.
Thank you.
Please Print this Page
Please print this Form
DATE
____________________
PO # if needed
______________________________________________
CONTACT NAME
___________________________________________
Please place a
checkmark
next to what best describes your Ship To address
When placing an order,
you may use either this Form,
or your own Purchase Order Form.
If using this form,
please include a Fax Cover
Sheet with it.
Legitimate
Commercial Address ____ Residential Address
____
SOLD TO:____________________________________________________________________________________________
ADDRESS
_____________________________________________________________________________________________
CITY
___________________________________________________________STATE _________
ZIP-CODE ______________
ADDRESS
______________________________________________________________________________________________
PHONE __________________________FAX
____________________________E-MAIL_________________________________________
CITY
____________________________________________________________ STATE
__________ ZIP-CODE _____________
SHIP TO:______________________________________________________________________________________________
QTY
CAT # / MODEL #
DESCRIPTION
UNIT PRICE
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
CREDIT CARD TYPE: M/C____ VISA ____
DISC____ AMEX____
SHIPPING COST _____________
______________________________________________________________________________________________________________________________________
CREDIT CARD #
___________________________________________________________
CARDHOLDER'S NAME
_________________________________________________________________________
* if this page does not print properly for you,
please advise us by e-mail at
sales@little-giantpump.com
and we will forward you a copy of it, that you can print............
Thank you
EXP. DATE ________________
3 OR 4 DIGIT REF.
CODE ____________________
your UPS ACCOUNT
#
________________________________
if you prefer that shipping be billed directly to
your own
UPS or FED-EX Account,
or that your order be shipped Freight Collect
via your own preferred LTL Carrier, please provide that information below:
if the Billing
Address for your Credit Card,
is not the same as your Sold To address or Ship To address,
please provide that address below.
IF SHIPPING Freight Collect
via LTL, your preferred
Carrier:
________________________________
CITY _____________________________________________
STATE ____________
ZIP-CODE _____________
BILLING ADDRESS of CARD
___________________________________________________________________________
your FED-EX ACCOUNT
#
________________________________