Billing Information:  *Denotes Required Field for OPEN account orders:
*Your Account Number (If you enter your account number, skip
         *Purchase order # down to the items you wish to order.)
                 Your name*    
          Company Name      
                       Address
                                    
                              City State*Zip
          Phone Number*
        E-Mail Address*
              

                 To ship to a DIFFERENT address than the bill to:

          Ship to Company Name
                       Ship to Address
                                                
                              Ship to CityStateZip

  Quantity    Part Number                           Description
      
      
      
      
      
      
      
      
      
      

Are Backorders Acceptable?  Yes, OK to Backorder   No, Cancel Backorders 

Ship by way of:    UPS    FedEx    RPS    MOTOR FRT (specify truck line preference in comments) (Note:  Freight charges are added to each invoice.)

Priority of shipment:     Next Day Air/Priority 1  (only on orders received before 2pm)
                                       2nd Day Air
                                       3 Day Select
                                       Ground  
 Additional Comments or Instructions: (Enter your request if you are not sure of the part numbers. We will be glad to assist you.)

Billing:  Credit Card*   Open Account**   (Sorry, No COD's accepted.)
*(For Credit Card Orders--Fill out form and submit it to us, be sure to include your phone number so that upon receipt of your order, we can call you back for your credit card billing information.  Your security and privacy are top priorities with us!  Call for information on international orders.)

We accept:  VISA, MasterCard, Discover Card, American Express

*Do not list your card number here, or in any forms traversing the Internet!  See above instructions for ordering by Credit Card!.
**Open Account billing requests honored for existing accounts, and are subject to credit approval and established account rules.  For information, contact our credit department, (540)-389-7296.

           Thank you for your time and your order!