Order Form

Print and fax to (909) 591-2350

Order Date ______________
Name ________________________
Title _________________________ 		Purchase Order # _______________
ShipTo ___________________
_______________________
_______________________
_______________________
Bill To ____________________
________________________
________________________
________________________
Phone # (      ) ________________
Fax # (      ) ___________________
Email ________________________
Item # Name/Description Quantity Unit Price Total
         
         
         
         
         
Sub-Total  
CA Residents add 7.75% Sales Tax  
Shipping (see below)  
Total  

Method of Payment (Check one)        (   )VISA®    (    )MasterCard®    (    )American Express®   (   )Discover® 

Card #___________________________Exp. Date________

 

Card Holders Name_________________________________

 

Card Holders Signature______________________________

 


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*Orders are shipped FOB from our nearest location at the discretion of PCI Products Company. Freight charges are to be prepaid 
and will be added to your invoice. Product weights in catalog are approximate.

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