CONFIRMATION OF PURCHASE ORDER

DATE OF ORDER: ______________________

P. O. # (IF APPLICABLE): _______________

BILL TO: SHIP TO:

____________________________________ ______________________________

____________________________________ ______________________________

____________________________________ ______________________________

____________________________________ ______________________________

PRODUCT: DISCOUNT: ___________________

TERMS: ______________________

QUANTITY: ___________________

NO CHARGE OFFSET PRODUCT: _________ ($__________) @ RETAIL VALUE.

SYSTEM: NET COST: _____________________

TERMS: ________________________

FREIGHT FOR PRODUCT AND SYSTEM: _______________________

SHIP DATE: (Pending credit approval): ___________________________

______________________ ___________________ _________________

Authorized Signature Title Date

Please complete and return to ______________________________ Sales Department

FAX # ____-____-_______

THIS ORDER WILL BE HELD UNTIL RECEIPT OF THIS SIGNED FORM.

Thank You.