GENERAL INFORMATION

Name:

Title: 

Organization:

Work Phone:

Work Fax:

E-Mail:

 

Card Holder Signature

 

 

 In signing this form, you agree your credit card information is valid and that the billing address is correct.

 

 

 

 

 

CREDIT CARD INFORMATION
Card Type:

 
Card #:

---
Exp Date:

/

   

Is Billing & Ship to the same      If "Yes" you do not need to fill out the "SHIP TO ADDRESS"
Is Ship Address a business       Shipments to a residents adds $2.00 to S&H charges.
 

BILLING ADDRESS

  

 

SHIP TO ADDRESS
 

(where the credit card bill is sent)

    

(where is the order being shipped)

Name:

 

Name:

Address:

 

Address:

Address:

 

Address:

City:

 

City:

State:

 

State:

Zip:

 

Zip:

ORDER SUMMERY

Qty

 Description

   Price ea   Ship Via:

 

$

 

 

$

 

 

 

$

 

Shipping & Handling Charge

 

$

 

$
COMMENT

Fill out form, print, sign and fax it to us at 1-317-535-3734. If you prefer not to fax your credit card information, please omit credit card number and call this information into us at 1-800-710-4253.
Faxing this form means your agree to all TERMS and condition of sale.
Copyright © 2000, 2001, 2002, 2003, 2004  Gale Engineering, Inc.
All rights reserved.  Revised: 08/21/07