| 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 | |||||||
| 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) | ||||||
CARD NUMBER 3 digit sec. number | |||||||||||
| IL
RESIDENTS Add 7.25% Sales Tax | |||||||||||
| AUTHORIZED
SIGNATURE | Postage & Handling | ||||||||||
| EXPIRATION
DATE (mo/yr) | TOTAL DUE | ||||||||||