Eberly Purchase Order Form

Purchase Order Form

ORDER PLACEMENT Orders may be placed by telephone, e-mail, fax or postal service.
We will confirm receipt of your order, including all costs and ship date, via e-mail, fax or telephone.

PROPER FULFILLMENT To have your order correctly processed, it is important that you provide all requested information. Please type the catalog number, product description, unit, ("each" unless noted otherwise) and quantity requested.

TERMS Minimum purchase order value US$25.00. Payment must be in US funds. No C.O.D. We accept prepayment by check, American Express, Discover, MasterCard or VISA, or for approved credit, net 30. References are required from three current suppliers.

CREDIT CARD PAYMENT For American Express, Discover, MasterCard or VISA payment, please fax the order or provide account number by telephone. Include card issuer, name on card, mailing address, card number and expiration date.

EXPORT Purchases from outside the USA or Canada require either prepayment of all charges, American Express, Discover, MasterCard or VISA, or an irrevocable letter of credit, and customs broker name, address and telephone number. Payments must be in US Funds.
Payments must be in US Funds.

Contact Information

Contact Name:
Order Number:
Telephone Number:

Fax Number:
Email Address:
NY Sales Tax Exemption:
Payment Option:

Billing Information

Billing Name:
Billing Address:
City:

State/Province:
Zip/Postal Code:
Country:

Shipping Information

Ship to Name:
Ship to Address:
City:

State/Province:
ZIP/Postal Code:
Country:
Ship Option:
Please Explain Other:
Special Instructions or Requests:

Catalog Number	Description	Unit	Quantity	Price	Total