INTERNET ORDER FORM (Please print & fax or mail) 

4328 REDWOOD HWY #100 SAN RAFAEL,94903

FAX (415) 479-2745

Phone:  TOLL FREE (800) 752-8884 in USA, or (415) 479-6400 outside USA

Customer:

Customer Acnt#:            Date:

Address:

Customer PO #:

City:                                   State:      Zip:

Salesman:

Ship to (If different):

Ship Date:

Address:

Ship via [ ] UPS [ ] Mail [ ] Other

City:                                   State:      Zip:

Terms [ ] Net 30 [ ] COD [ ] Credit Card

 

QTY

CATALOG #

DESCRIPTION

PRICE