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          Print, fill and fax to (818) 854-6178. Back?home

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          Purchase Order

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          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:_____________________________________? ?

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          Payment Details

          Please indicate your resale number: Circle only one?Purchaser
          _________________
          ?Company Check Casher Check Wire Transfer Credit Card (If credit card, please continue with CC info) Credit Card Name
          (VISA, MC, Amex, Discover) Card Holders Name Card Number Exp Date ? . . . . . . ?

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