GENERAL INFORMATION

Name:

Title: 

Organization:

Work Phone:

Work Fax:

E-Mail:

   

 

 

 

 

 

CREDIT CARD INFORMATION

    
Card Type:

 
Card #:

---
Exp Date:

/   3 Digit code

   

Is Billing & Ship to the same      If "Yes" you do not need to fill out the "SHIP TO ADDRESS"
Is Ship Address a business       Shipments to a residents adds $2.00 to S&H charges.
 

BILLING ADDRESS

  

 

SHIP TO ADDRESS
 

(where the credit card bill is sent)

    

(where is the order being shipped)

Name:

 

Name:

   

Address:

 

Address:

   

Address:

 

Address:

   

City:

 

City:

   

State:

 

State:

   

Zip:

 

Zip:

   
ORDER SUMMERY

Qty

 Description

   Price ea                

  $  

Ship Via:

           

  $   Shipping & Handling Charge $  (if pre quoted)            

  $  

Ref PO#

            

  $                
COMMENT

Press submit button below to e-mail this form. If you prefer not to e-mail your credit card information, please omit credit card number and call this information into us at 1-800-710-4253. If you would prefer to fax a form, Click here to be taken to a Printer Friendly Form. Information entered will not be transferred to the new form.

   

Submitting or faxing this form means your agree to all TERMS and condition of sale.
Copyright © 2000-2007  Gale Engineering, Inc.
All rights reserved.  Revised: 04/20/08