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.