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| Order Form |
| 3372 Burke Road, Sun Prairie, WI 53590 |
| Quantity Part Number Description _______ _________________ __________________________________________ _______ _________________ __________________________________________ _______ _________________ __________________________________________ _______ _________________ __________________________________________ _______ _________________ __________________________________________ _______ _________________ __________________________________________ _______ _________________ __________________________________________ _______ _________________ __________________________________________ _______ _________________ __________________________________________ _______ _________________ __________________________________________ _______ _________________ __________________________________________ _______ _________________ __________________________________________ |
| Ship To: (if different) Name:______________________________ Address:____________________________ City:___________________ State:______ Zip:_____________ |
| Bill To: Name:_____________________________________ Address:___________________________________ City:___________________ State:_____________ Zip:_____________ Phone #:__________________ (required) |
| Shipping Information: ____ UPS Ground ____ UPS 3 Day Select ____ UPS 2nd Day Air ____ UPS Next Day Air |
| Subtotal: ________ |
| Tax: 5.5% (Wis. residents only) ________ |
| Shipping Charges Will Be Added To Total |
| Payment Information: ____ COD ____ Credit Card Card Brand:_______________________ Card Number: _____________________ Exp. Date:________ Zip Code:________ Signature:_________________________ |