Bill To

Ship To (if different)

Company: 

Company: 

Full Name:

Full Name:

Address 1:

Address 1:

Address 2:

Address 2:

City/Prov.:

City/Prov.:

State, Zip:

State, Zip:

Telephone:

Telephone:

Electronic Delivery:  Free

Ship via UPS:

    Send instructions for downloading the ordered products
          to the email address shown below:

    UPS Next day - $15      UPS 2nd day - $10
    UPS 3rd Day  - $ 7       UPS Ground -  $ 5

Payment by Check                       

Payment by Credit Card

Purchase Order #:

Card#

Fed. ID / Soc. Sec:

VISA      MC     Discover   AMEX

Dunn & Bradstreet:

Name: 

Item

Product
Code

Product Description

Qty

Price Ea

Extended
Price

1

2

3

4

5

6

* Shipping charges are only applicable to orders within the continental USA.
   Electronic Delivery must be used on all non-continental USA orders. 

Subtotal

Sales Tax

Shipping*

Grand Total

TERMS:  Payment may be made by either VISA, MC, Discover Card, American Express, or company check.  After approval of a company's credit Purchase Orders with net 30 terms will also be accepted.  The Invoices of approved companies will be subject to a 2% per month late payment charge.  Your acceptance of these terms is indicated by your signature below:

  
Signature: __________________________________    Date: ______________