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.