567 / 571
Qty.
Stk. No.
Size (ea., dz., etc.) & Description (color, voltage, etc.)
Unit
Price
Total
Price
Sub-total
Add Total from Additional Page(s)
Merchandise Total
Add 10% of
Merchandise Total
, $15.00 minimum
(for Shipping, Handling & Insurance)
Add Sales Tax on
Merchandise Total,
if applicable
TOTAL
Mfr. No.
SIGNATURE
________________________________________________
We will back order any item temporarily out of stock & ship when stock is received.
5 Convenient Ways to Order . . .
• Phone
(800) 831-5904
• Fax
(800) 285-7054
• Web
midwesttechnology.comP.O. Box 3717, Sioux City, IA 51102
Bill To:
Purchase Order No. ____________________________________
School (Company) ______________________________________
Address _____________________________________________
City _____________________ State ______ Zip ____________
Department __________________________________________
Date __________ Phone No. ____________________________
Email _______________________________________________
Ship To:
Attn./Dept. ____________________________________________
School (Company) _______________________________________
Street ________________________________________________
City _____________________ State ______ Zip _____________
Ordered By____________________________________________
Phone No._____________________________________________
Email ________________________________________________
Credit Card No.
Expiration Date
SIGNATURE
______________________________________________________
Special Order Instructions _________________________________________________________________________________________
_____________________________________________________________________________________________________________
(V) Security Code
(near signature)
2 0 1 6 C a t a l o g
ORDER FORM
P.O. Box 3717 • Sioux City, Iowa 51102
Payment Method:
Visa
MasterCard
Discover
Certified Check
Please ship ASAP
Please schedule delivery between ____________ & ___________
We t h a n k y o u f o r y o u r o r d e r !
•
A shipping, handling & insurance charge of 10% of total merchandise value will be added to
all orders shipped within the 48 contiguous United States subject to a minimum charge of $15.00.
•
Actual transportation charges are prepaid & added to the invoice of all orders that ship outside of the 48
contiguous United States. These transportation charges will be added to all orders shipped to Alaska & Hawaii.
Attention:
Hazardous Materials including ORM-D, as defined by Federal Regulations, will not be sent to Alaska or Hawaii.
Open Account with PO No.
(schools only) __________________________________________________________________________