Secure Order Form

NOTICE: You must use Internet Explorer browser to send this form. Mozilla or other browsers will not currently work.

Before attempting to fill in this form, write on paper all information about products you want to order. Fill in all blanks, especially REQUIRED

ones marked with red asterisk (_*)then click Submit Form. Do not press ENTER or RETURN keys on your keyboard until you have

completed this form and are ready to submit your order.

*Your Name		Must match name on your ` credit card
Company/Organization
*Street Address
*City		Business or Residence
*State/Province		Must match address on credit card statement
*Zip/Postal Code	Country
*Phone	FAX
*E-mail		Double check your entry!

Qty	Item/Brand	Model Mfg No		Unit Price	Total Amt



You can avoid add back of the cash discount by using company check see DETAILS			3% cash discount add back

*Payment Method

Card Type

Card Number


Expiration Date		MM/	YY	CVV2 Code		What's this?	Name on card

WARNING: Imprisonment for ten years and a $10,000 fine just for the attempt of credit card theft or fraud. see DETAILS

SHIPPING ADDRESS (if different than billing address)
Street	Business OR Residence
City		State/Province	Zip/Postal Code
Comments: I have read and understood Terms and Conditions (found at this link) before placing this order.

PRINT A COPY OF THIS ORDER FOR YOUR RECORDS

Fax 317-573-9060 division of ABC Company LLC., 1089 Third Ave SW, Carmel, IN 46032-7540 Phone: 317-573-9061