The Gallup Store Order Form
Email to gallupstore@gallup.com Fax to: The Gallup Store at 1-888-500-8282 Mail to The Gallup Store 1001 Gallup Drive Omaha, NE 68102 Phone: 1-888-525-6117
Office Use Only: Order #______________________ Date Received ________________
Billing Information: Name: ______________________________________________________ Company: ___________________________________________________ Address (no P.O. Boxes): _______________________________________ ____________________________________________________________ City: ________________________________________State: __________ Zip: ____________________Phone: (___) _________________________ Email:_______________________________________________________ Shipping Information ___ Check if shipping is the same as Billing Information Name: ______________________________________________________ Company: ___________________________________________________ Address (no P.O. Boxes): _______________________________________ ____________________________________________________________ City: ________________________________________State: __________ Zip: ____________________Phone: (___) _________________________ Email:_______________________________________________________ Payment Information Credit Card: MC VISA DISCOVER AMEXPRESS Account Number: ____________________________Security Code:_____ Exp. Date: ___________ Name on Card: __________________________ Other Methods of Payment: Purchase Order #: _____________________________________________
Item: ____________________________________________ Quantity: Item: ____________________________________________ Quantity: Item: ____________________________________________ Quantity: Item: ____________________________________________ Quantity: Item: ____________________________________________ Quantity: Item: ____________________________________________ Quantity: Item: ____________________________________________ Quantity: Item: ____________________________________________ Quantity: Item: ____________________________________________ Quantity: Item: ____________________________________________ Quantity: Item: ____________________________________________ Quantity: Item: ____________________________________________ Quantity: _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______
Shipping Information: Ground / 2-Day / Next Day Air
Authorized Signature of person ordering: ______________________________ Printed Name of person ordering: ____________________________________
Dealers, libraries, schools, and educational institutions may submit purchase orders provided orders are submitted by authorized personnel using a valid Purchase Order (P.O.) number. When mailing orders, please address the P.O. to Gallup Press.
"INVOICES ARE DUE UPON RECEIPT IF ORDERS ARE NOT PRE-PAID BY CHECK or CREDIT CARD"