CONFIRMATION OF PURCHASE ORDER
DATE OF ORDER: ______________________ P. O. # (IF APPLICABLE): _______________ BILL TO: ____________________________________ ____________________________________ ____________________________________ ____________________________________ SHIP TO: ______________________________ ______________________________ ______________________________ ______________________________
PRODUCT: DISCOUNT: ___________________ TERMS: ______________________ QUANTITY: ___________________ NO CHARGE OFFSET PRODUCT: _________ ($__________) @ RETAIL VALUE.
SYSTEM: NET COST: _____________________ TERMS: ________________________
FREIGHT FOR PRODUCT AND SYSTEM: _______________________ SHIP DATE: (Pending credit approval): ___________________________
______________________ Authorized Signature
___________________ Title
_________________ Date
Please complete and return to ______________________________ Sales Department FAX # ____-____-_______
THIS ORDER WILL BE HELD UNTIL RECEIPT OF THIS SIGNED FORM. Thank You.