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ORDER FORM FAX: 04 237 2513POSTAL ADDRESSCompany: _ _________________________________________________________Address:_ ________________________________________________________________________________________________________________________________Suburb: _____________________________________________________________Town/City: __________________________________________________________Phone: ( )________________________________________________________Email: ______________________________________________________________Purchase Order No: ________________________________________________Ordered By: ________________________________________________________Signature: __________________________________________________________DELIVERY ADDRESSCompany: _ _________________________________________________________Address:_ ________________________________________________________________________________________________________________________________Suburb: _____________________________________________________________Town/City: __________________________________________________________PREFERRED DELIVERY METHOD❏ Please use Freight Free PRIORITY delivery❏ Please use Special RURAL delivery – charges apply❏ Please use Overnight RAPID delivery – charges applyMY ORDERCODE DESCRIPTION QUANTITY UNIT PRICE TOTAL PRICEPrices exclude GST GOODS TOTALHandling Fee $6.00MY PAYMENT DETAILS❏ Please invoice my account❏ I wish to apply for a 30 Day Account❏ Please charge my credit cardEXTRA INFORMATIONNature of business:_______________________________________________________________________________________________________________________No. of employees: __________________________________________________I/We hereby apply for a credit account with <strong>Powerpac</strong> <strong>Group</strong> and agree to abide by the Terms & Conditions of Sale. A copy of the Terms of Tradefor <strong>Powerpac</strong> <strong>Group</strong> is available on request. Invoices are due for payment on the 20 th of the following month.SIGNED: _______________________________________NAME: _________________________________________DATE: ______ /______/____________CREDIT CARD DETAILS (only required if this is your preferred payment method)❏ Mastercard ❏ VisaCard No:Expiry Date: _ ______ /______/____________CCV #:______________Cardholder’s Full Name: _ ______________________________________________Cardholder’s Signature: ________________________________________________All Prices Exclude GST PHONE: 0800 23 57 89 EMAIL: onsite@powerpac.co.nz PAGE 7
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