FAX ORDER TO: 1-800-724-3040 or CALL US AT 1-800-724-3030
BILL TO:
CUSTOMER NO.:
_______________
Name:
Address:
City:
State:
Zip:
Tel. No.:
Fax No.:
E-Mail:
Order Date:
Ship Date:
Purchase Order No.:
SPECIAL INSTRUCTIONS:
SHIP TO:(if different than above)
Name:
Address:
City:
State:
Zip:
LINE
NO.
PROD.
NO.
DESCRIPTION
UNITS
/ CASE
CASES ORDERED
COST
/ CASE
TOTAL
1
2
3
4
5
6
7
8
9
10
11
12
**Where
the order total is less than your base amount for prepaid freight, freight will be added
to the product total.
**TOTAL:
$
ALL SALES MADE IN
ACCORDANCE WITH THE COMPANY "TERMS AND CONDITIONS OF SALE".
NO RETURNS ACCEPTED WITHOUT PRIOR FACTORY AUTHORIZATION IN WRITING
BUYERS SIGNATURE: x
Please Print Name:
Please complete
Method of Payment: section that follows and include with your order
METHOD OF PAYMENT:
(PLEASE CHECK ONE OF THE FOLLOWING)
[ ] Charge Account (Send
an Invoice)
[ ] Credit Card Payment
(Fill in the information below)
Cardholder Name (on card):
Cardholder Address:
City:
State:
Zip:
Visa [ ]
Master Card [ ]
Card No:
Expiry Date:
Amount Total: $
The
undersigned cardholder hereby authorizes AtenPac Corporation Inc. to electronically charge
its account in the above amount. AtenPac is authorized to amend the above amount if any
item(s) are short shipped or if extensions of amounts are in error. Returns are not
accepted. Any shipment damaged in transit or missing parcels must be noted on the carrier
receipt at the time of delivery and it is the sole responsibility of the cardholder or its
agent to claim for damaged or lost parcels directly with the carrier.
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