| PURCHASE ORDER (this form can be printed for mail order) | Please Check One |
RLBPS 4827 Treeview
Terrace Phone: 815-874-5351 Email;orders@rlbps.com |
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| Name | Back Order any item(s) not in stock | ||||||||
| Street Address | Refund any items not in stock | ||||||||
| City | State | Zip | Issue credit card slip on any items(s) not in stock | ||||||
| Country | List Substitutions | ||||||||
| Phone | Date | This form is not required for e-mail orders. | |||||||
| QTY | ITEM NUMBER | MANUFACTURER | DESCRIPTION | COST | TOTAL | ||||||
| SUBTOTAL | |||||||||||
| PAYMENT | DISCOVER | VISA | MASTERCARD | Pay Pal | DISCOUNTS (if applicable) |
Christmas sale all instock items 10% 0ff untill Christmas | |||||
| CARD NUMBER | |||||||||||
| IL
RESIDENTS Add 7.25% Sales Tax |
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AUTHORIZED
SIGNATURE
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Postage & Handling | ||||||||||
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EXPIRATION DATE (mo/yr)
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TOTAL DUE | ||||||||||