Print this form and fax to 831-536-1098 (phone 831-726-7114)

Customer Information
Name as it appears on credit card

Your name if different than above

Shipping address

City State Zip

Phone Fax E-mail

Method of Payment Visa or Mastercard #
Expiration Date **/**/** or **/** as shown on card

Quantity	Unit	Description	Unit Price	Extended Total
K Rubber checks are subject to $40 recycling fee. J Returns require an authorization number and are subject to a 15% re-stocking fee. L 1 1/2% added each month to past due accounts. J Please submit resale card for tax exempt sales.			Sub Total
			Sales Tax
			Shipping
			Total

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