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/ Software Vault: The Gold Collection / Software Vault - The Gold Collection (American Databankers) (1993).ISO / cdr11 / supratxt.zip / ORDER.TXT < prev    next >
Text File  |  1992-08-07  |  4KB  |  58 lines
  1.                            Supra Corporation
  2.  
  3.                            MODEM ORDER FORM
  4.  
  5.    ---------------------------------------------------------------------
  6.   |                       PERSONAL INFORMATION                          |
  7.   |                                                                     |
  8.   | Name:________________________________   Phone:_____________________ |
  9.   | Company:_____________________________   FAX:_______________________ |
  10.   | Address:_____________________________   BBS:_______________________ |
  11.   | City:________________________________   ___________________________ |
  12.   | State:_______________________________                               |
  13.   | Country / Province:__________________                               |
  14.   | Zip:_______________                                                 |
  15.    ---------------------------------------------------------------------
  16.    --------------------------------------------------------------------- 
  17.   |                         ORDER INFORMATION                           |
  18.   |                                                                     |
  19.   |  Date_________________  Order #_____________  Cust PO#_____________ |
  20.   |  BILL TO:__________________________________________________________ |
  21.   |  Address:__________________________________________________________ |
  22.   |  City:________________________ State:__________ Zip:_______________ |
  23.   |  Country / Province:___________________________                     |
  24.   |  Contact Name:_____________________________________________________ |
  25.   |  SHIP TO:__________________________________________________________ |
  26.   |  City:________________________ State:__________ Zip:_______________ |
  27.   |  Country / Province:___________________________                     |
  28.   |  Referred by:______________________________________________________ |
  29.    ---------------------------------------------------------------------
  30.    ---------------------------------------------------------------------
  31.   |                     PRODUCT INFORATION                              |
  32.   |                                                                     |
  33.   |  Item:______________________________________                        |
  34.   |  Part #_____________________ (Please refer to Retail Price Lists)   |
  35.   |  Price:_____________________ Qty:______________                     |
  36.    ---------------------------------------------------------------------
  37.    ---------------------------------------------------------------------
  38.   |  SHIPPING:               QTY:   BILLING:                            |
  39.   |  __ Ground      $ 8.00/pc ___   __ Visa:___________________________ | 
  40.   |  __ Blue Label  $14.00/pc ___   __ M.C. ___________________________ |
  41.   |  __ Red Label   $30.00/pc ___           Exp. Date:_________________ |
  42.   |  __ CANADA Mail $16.25/pc ___   __ Cashiers Check (COD $5.00 charge)|
  43.   |  __ CANADA Exps $43.25/pc ___   __ Pre-Pay  (No Personal Checks)    |
  44.   |                                                                     |
  45.   |  INTERNATIONAL:                  QTY:                               |
  46.   |  __ FedEx 1st piece    $90.00    ___                                |
  47.   |  __ Additional pieces  $20.00    ___                                |
  48.   |                                                                     |
  49.   |  TOTAL COST:_________________                                       |
  50.    ---------------------------------------------------------------------
  51.    ---------------------------------------------------------------------
  52.   |  COMMENTS:                                                          |
  53.   |  __________________________________________________________________ |
  54.   |  __________________________________________________________________ |
  55.   |  VERIFIED BY:__________________________  DATE:_____________________ |
  56.    ---------------------------------------------------------------------
  57.   Please fill out and send or FAX to Supra. (Do not upload to this board).
  58.