|
Please
PRINT, COMPLETE and FAX to 510-848-3366
Earthquake Gas Valve Source Berkeley, California, USA Tel. 510-843-3275 Fax 510-848-3366 www.EarthquakeValve.com |
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Shipping
Address - PLEASE
PRINT CLEARLY Company Name________________________________________________________________ Street Address_________________________________________________________________ City, State, Zip_________________________________________________________________ Telephone No. _____________________________Fax No. _____________________________ |
|
Credit Card Information
- PLEASE PRINT CLEARLY VISA MASTERCARD DISCOVER AMERICAN EXPRESS - PLEASE CIRCLE ONE Card Number__________________________________________Exp. ____________________ Card Verification Number: (On the back
of your card, locate the final 3 digit number. For American Express
cards, Telephone No. ______________________________Signature ___________________________ |
| Order / Quote Request
- PLEASE CIRCLE
ONE Qty______ Price___________ Description_________________________________ Total_______________ Qty______ Price___________ Description_________________________________ Total_______________ Qty______ Price___________ Description_________________________________
Total_______________ |
| Total ________________________________________
California Sales Tax 8.75% ______________________ Shipping & Handling ___________________________ Total ________________________________________ |
Shipping & Handling
Fees*: . |
Notes