PROSPECT Date: ____________________ Order Taken By: __________________________________ PROSPECT Date: ____________________ Order Taken By: __________________________________
CUSTOMER Customer ID: __________________ Purchase Order # _________________________
| Bill To: | Ship To: | ||||
| Address: | Address: | ||||
| City | State: | Zip: | City: | State: | Zip: |
| Contact: | Title: | Contact: | Title: | ||
| Phone: | Phone: | ||||
| Fax: | Fax: | ||||
Referred By: Phone Book Web Site Brochure Salesman Contact Other__________________
Shipping Method: UPS Red Blue Ground Gen Serv Customer Pickup Yellow Freight
Payment Method: Credit C.O.D Visa MasterCard American Express
Card Number: ______________________________________________ Expiration Date: _________________
If a customer is applying for credit, the order cannot be shipped until the application is approved. If a
customer is paying via credit card, please supply the credit card form for a signature.
QTY. | ITEM NUMBER & DESCRIPTION | LIST | COST |
Print: ______________________________________Sign: _______________________________