Order by FAX Form
Fax 740.652-9089 
(print and fax)

Please provide the following information to complete your order
(please print and write clearly)

QUANTITY Item# Description Case of Price Each Case Price
. . . . . .
. . . . . .
. . . . . .
. . . . . .
. . . . . .
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Must provide Credit Card Information below:

Your Information
Vendor #: (if you have one)
________________________		 Company Name:
______________________________
Name: ________________________ Address:
______________________________		 City, State, Zip
___________________________________
Phone:
________________________		 Email:
______________________________
Shipping Information (If different from above)
Name: ________________________ Address:
______________________________		 City, State, Zip
___________________________________
Phone:
________________________
Credit Card Information
Visa  MasterCard
Card Holder's Name:
(if different from above)		 Credit Card Number: Expiration Date:
__________________________ __________________________ __________
Card Holders Information (if different from above)
Name: ________________________ Address:
______________________________		 City, State, Zip
___________________________________
Phone:
________________________

Shipping charges will be added to the order according to current published UPS rates
__ Check here for shipping charges confirmation of amt. before shipping