Ampac USA- Product Order Form
Print, fill and fax to (818) 854-6178. Back home
Purchase Order
Company Name: ___________________________
Address: _________________________________
City: ____________________________________
State: ___________________________________
Zip: _____________________________________
Phone: __________________________________
Fax: _____________________________________
Contact: _________________________________
Email: ___________________________________
P/O#: ____________________________________
Date: ___________________________________
Ship By: _________________________________
Terms: __________________________________
Item: ____________________________________
Description: ______________________________
Qty: ____________________________________
Price: ___________________________________
Sub Total: ________________________________
Shipping & Handling: ______________________
Tax: _____________________________________
TOTAL: ___________________________________
Payment Details
Please indicate your resale number: Circle only one
Purchaser: _________________
Company Check | Casher Check | Wire Transfer | Credit Card
If credit card, please continue:
Credit Card Name (VISA, MC, Amex, Discover)
Card Holder’s Name: _________________________
Card Number: _______________________________
Exp Date: ___________
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