REPRESENTING

Date:
ORDER FORM
Mail to: POTTORFF - AIR PRODUCT SALES
Customer Acct #:
6490 Fleet Street
Commerce, CA 90040
Order Desk: (323) 728-0004
Fax to: 323-889-4825
PO #:
BILL THIS ORDER TO:
Name:
Address:
City: State: Zip:
Phone:
E-mail:
SHIP THIS ORDER TO: (if different than billing addess)
Name:
Address:
City: State: Zip:
Phone:
E-mail:
Catalog
Number
Model #
Quantity
Ordered
Description of Product
Price
per unit
Total
Price
METHOD OF PAYMENT
(Please circle)
Check Money Order Credit Card
Card#
VISA MASTERCARD
AMER/EXPRESS DISCOVER
SUBTOTAL:
TAX:
TOTAL:
Exp. Date:
Signature:
Tax Exemption #:
THANK YOU FOR YOUR ORDER!