2018 Equipment & Parts Catalog

Attention: ________________________________ Order Date:________________ Time Faxed:___________________________ Customer Number: _______________

Purchase Order No.: ____________________________________________________ Bill to: ________________________________________________________________ Company Name:________________________________________________________ Address: ______________________________________________________________ City, State, Zip: ________________________________________________________ Phone No.: ____________________________________________________________ Fax No.: ______________________________________________________________ E-mail: _______________________________________________________________

Ship to: _______________________________________________________________ Company Name:________________________________________________________ Attention: _____________________________________________________________ Address: ______________________________________________________________ City, State, Zip: ________________________________________________________

FAX ORDER FORM

Ship via: T COD T UPS ground T Mail T Next day air T 2nd day air T Best way T Truck

Visa, Mastercard, American Express or Discover No.: ________________________________________________________________________________ Exp. Date: ______________________

T Ship complete orders T Ok to back order Warehouse Codes : PA -Biglerville, PA, OH -Bellevue, OH, IN -Peru, IN and B/O -Back order T Ship from any available warehouse

Avail Whse

Catalog Year and Page No.

Unit Price

Extended Price

Quantity Part No.

Description

Special instructions: ______________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

Please T call T or fax back with a total of this order. Attention: ______________________________________ T Please notify me if part numbers need to be back ordered

240 | INDEPENDENT AG EQUIPMENT PRODUCT CATALO G | PA: 800-345-3546 | OH & IN: 800-848-8460 | www.IndependentAg.com