Price Industries Fax Order Form

Fax to 1-800-506-6217

 

PLEASE NOTE: For Credit card verification: Name, Address, Zip Code, and Phone Number

must be the same as that on your Statement from the Card Provider.  Thanks

We use USPS for shipping.

Please print clearly, and use a dark pen, thank you.

 

Bill to:                                                                                Ship to: (If different than Bill To)

 

Name _______________________________*                Name ______________________________

 

Address _____________________________*                 Address ____________________________

 

Address _____________________________                   Address ____________________________

 

City _________________________________*                City _______________________________

 

State ______* Zip Code _________________*                 State ______ Zip Code _______________

 

Phone _______________________________ *                 Fax ______________________________

 

E-mail (for email conformation of ship date)_______________________________________________

 

Part Number __________Quantity __________Price _______________

Part Number __________Quantity __________Price _______________

Part Number __________Quantity __________Price _______________

                                                                   Sub Total _______________

                                                                   FL Tax ________________  7% FL residents only

                                                                   Shipping _______$ 5.00____

                                                          Total for Order________________

 

 

Visa ____MasterCard ____Card Number  ___________-___________-___________-___________

 

 

Exp. Date _________________ Name as it appears on card  _______________________________

 

 

Signature _______________________________________

 

 

 

 

                   Thank You for Your Order!!!