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

 

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

                   Copyright 1998-2008 ABC Company LLC  .  All rights reserved.                                                                                    Revised: May 15, 2013