Name ________________________Order #
Address ______________________ Email _____________@________
City _______________________ State ___ Zip _______
Phone ___-_____-_____ Fax ___-____-______
Card or Check # _________________________
Shipping Information :
Name _______________________________
Address 1 _________________________
Address 2 ___________________________
City ______________ State ________ Zip ______
Phone ____-____-_____ Fax ___-____-_______
Products Ordered :
Item Number ____________ Description __________________ Price ______ Your Price _________
Item Number ____________ Description __________________ Price ______ Your Price _________
Item Number ____________ Description __________________ Price ______ Your Price _________
Item Number ____________ Description __________________ Price ______ Your Price _________
Item Number ____________ Description __________________ Price ______ Your Price _________
Item Number ____________ Description __________________ Price ______ Your Price _________
Item Number ____________ Description __________________ Price ______ Your Price _________
Total ____________________
Discount___________________
Total __________________
Shipping ___________________
Grand Total _________________
Accept Back Order____________
Use additional if needed.
Fax to 865-674-2870.
Office Use Only ________ Customer ____Date ____ Filled _____#