Order
Form
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YOUR BILLING INFORMATION: |
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| Name | ||||
| Title | ||||
| Company | ||||
| Address | ||||
| Phone | ||||
|
YOUR SHIPPING INFORMATION: (Only if different from Your Billing Information) |
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| Name | ||||
| Title | ||||
| Company | ||||
| Address | ||||
| Phone | ||||
| PAYMENT METHOD: | ||||
| We
have a Stempf account, please bill us...
Our Stempf Customer Number is |
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| Send my First Order C.O.D. | ||||
| Please
open an account for my company* (Fill out application to open account below completely ONLY if you are FAXING or MAILING this form.) |
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| Please
charge my credit card (Fill out credit card information completely ONLY if you are FAXING or MAILING this form.) |
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|
*Open account credit line subject to credit approval. Please note: If you want to
open a line of credit or charge your order to a credit card, |
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|
APPLICATION
TO OPEN AN ACCOUNT (Fill out ONLY if you are FAXING or MAILING this form) |
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| Trade Reference | ||||
| Telephone | ||||
| City, State | ||||
| Trade Reference | ||||
| Telephone | ||||
| City, State | ||||
| Bank | ||||
| Telephone | ||||
| Account # | ||||
|
CREDIT
CARD INFORMATION |
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| VISA | ||||
| MASTER CARD | ||||
| DISCOVER CARD | ||||
| Name on Card | ||||
| Card Holder Signature | ||||
| Card Number | ||||
| Expiration Date | ||||
| CVV2 Code (3-4 digit code on back of card) | ||||
HERE'S WHAT WE NEED TO ORDER:
| Part Number | QTY | Description | Price Each | Extension |
|
Sub Total |
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| Shipping amount, Call us | ||||
|
C.O.D. Orders,
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| Sales Tax (If Applicable) | ||||
| Total | ||||
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