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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

• Email

orders@midwesttechnology.com

• Fax

(800) 285-7054

• Web

midwesttechnology.com

• Mail

P.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) __________________________________________________________________________