* Please Note: Purchase Orders must be $1000 or greater *

Instructions: To place a Purchase Order, please complete the following fields and print the completed form. Proceed by faxing the completed form to: 1.888.505.2375

Shipping Infomation
Name of Contact:
Name of Agency:
Division/Department:
Phone Number:
E-mail:
Shipping Address:

Billing Infomation
Name of Agency:
Phone Number:
Billing Address:
Purchase Order Number ( P.O. Number):

Order Items
	Product Name	Product Code	Unit Price	Quantity	Total
1.
2.
3.
4.
5.

			Subtotal
			Frieght
			Order Total

Special Instructions:
Shipping&handling fee: (For office use only)

Signature:

X ____________________________________________________________