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565 Westlake St., Bldg 100, Encinitas, CA 92024 Phone: 760.944.1048 Fax: 760-944-2959 |
Fax/Mail Order Form ORDER NUMBER (If any): |
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Customer Name: |
Ship To Address (If Different): |
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Credit Card Billing Address: |
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Customer Phone/Email/Fax: |
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ORDER Date |
requisitioner |
Ship via |
f.o.b. point |
terms |
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FedEx Ground |
San Diego |
Pre Pay |
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qty |
SKU / ITEM# |
description |
unit price |
total |
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CREDIT CARD PAYMENT (MC/VISA/AMEX ONLY) |
SUBTOTAL |
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Daytime Tel: |
SALES TAX (California Only 7.75%) |
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Name on CC: |
SHIPPING & HANDLING (SEE CHART) |
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Expiration Date: |
OTHER |
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CC #: |
TOTAL |
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Authorized by X___________________________
Date_______ Shipping
(Based on product weightl)
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Send all payments by check
to: Express Compaines, Inc. 565 Westlake St., Bldg 100 760.944.1048 E-MAIL: info@wholesale-first-aid-com |
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