*     Name

*     Company Name

*     Street Address

*     City

*     State

*     Zip Code

*     Phone

*     Email Address

NOTE:  If you choose Credit Card as your payment type, we will call you for the card number and expiration date.  If you are ordering by PO# and are a Tax Exempt organization, please fax a copy of your tax exempt certification.  After we receive your tax certification, we will process your order.

If you are a new customer and wish to purchase on Net 30 terms, please fax  or email a copy of your Company Credit History along with 3 business references.  After we receive your Credit History, we will process your order.