To place a product order, print this form
and fax the completed form to 508.990.0444.
SHIP TO:
COMPANY
STREET
P.O. BOX
BILL TO:
ATTN
STREET
P.O. BOX
CITY
STATE
ZIP
PHONE
FAX
E-MAIL ADDRESS
PAYMENT METHOD:
HOUSE CHARGE
C.O.D.
98 Spring Street
New Bedford, Massachusetts 02740-5939
Telephone 508-993-4770
Facsimile 508-990-0444
E-Mail: Briscobblue@verizon.net
PURCHASE AUTHORIZATION - To purchase please complete section below.
I authorize the purchase of the above with PO# or signature under terms listed.
PO/JOB REFERENCE
PRINT NAME
SIGNATURE
DATE
PHONE
FACSIMILE
E-MAIL ADDRESS
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