* Please Note: Purchase Orders must be $500 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: 1.626.363.0100


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 ____________________________________________________________