Order #___________(if applicable) UPS/FedEx Shipper #__________(if applicable)
| Quantity | Spacer Number | Description | Price Each | Total Price |
|
_____OD x _____ID x _____Long |
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|
_____OD x _____ID x _____Long |
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|
_____OD x _____ID x _____Long |
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|
_____OD x _____ID x _____Long |
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| Shipping --Add $8.00 to regular shipping cost if shipped COD | ||||
| Total -- | ||||
Ship to: Print this form, complete it and Fax it to 760-247-9118
Name/Attn:_____________________________________________
Company Name_________________________________________
Address____________________________________________
Address____________________________________________
City_____________________State_______Postal Code_________
Country_________________________
Phone #________________________ (Required outside of USA)
Email_______________________(This is so we can email confirmation and tracking numbers)
Circle Credit Card Type: American Express M/C VISA Discover
Credit Card #__________________________________
Expiration (Month/Yr)_______/________
Verification Number_______(Last 3 digits on the reverse side of card/4 digits on the face of AMEX)
Credit Card Billing Address: (If different from Shippng address)
Name___________________________________(Write 'Same' if same as above)
Company Name___________________________________________
Address____________________________________________
Address____________________________________________
City_____________________State_______Postal Code________