Order Form

ORDER & Fax FORM

Please review our Terms and Conditions before ordering since these apply to ALL orders! All prices are subject to change, due to irregular increases by manufacturers. We have a minimum $30.00 order requirement.

Fill out the following information then print the page and FAX your order to us at (800) EMS 1182, or click on the "Submit Order Form" button at the bottom of this page. We will confirm your order on our next business day, verifying payment plans, shipping and product availability. Be sure to include your telephone AND e-mail address as shown on the Order Form. NO credit card or payment information is needed at this time. Thank You!

ORDER FORM

   Name: *
Address: *
   City: *State: * Zip:*
Country: *

E-Mail Address: *

    (current) Customer No.:  (if applicable)
Order Placed by: *
      Phone No. & Area Code: *

Customer PO No.:  (if applicable)
       Ship Via:  (UPS, USPS, FED-X)

        Taxable:   Resale:  Out Of State:

   Special Shipping Requirements?: *

  * These boxes must be completed with order *

   Billing Info: Open Account:   Cash With Order:    C.O.D.
		Credit Card: (to be verified when we call or e-mail you)

      Order     Item No.                Description
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There is a 25% RESTOCKING Fee (see terms & conditions)

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