Melco EMT 10-6T

FAX – PART ORDER FORM *FOR DOMESTIC USE ONLY*

FAX TO: 303-457-0432 DATE:___________________________________________________ SHIPPING VIA CUSTOMER NAME:______________________________________ UPS: CUSTOMER NUMBER:___________________________________ RED (IF KNOWN) REDSAVER CUSTOMER ADDRESS:___________________________________ BLUE _________________________________________________________ GROUND

CUSTOMER PHONE #:____________________________________ CUSTOMER FAX #:_______________________________________ CUSTOMER E-MAIL:_____________________________________ MACHINE MODEL#:_______________ SERIAL #:_____________

SHIPPING INFORMATION: SAME AS ABOVE COMPANY NAME____________________________________________________________ SHIPPING ADDRESS_________________________________________________________ _____________________________________________________________________________ CITY________________________________________________________________________ STATE______________________________________________________________________ PHONE______________________________________________________________________

METHOD OF PAYMENT:

MASTERCARD

VISA

AMERICAN EXPRESS

CREDIT CARD #: NAME ON CREDIT CARD:_____________________________ EXPIRATION DATE:

MONTH YEAR SIGNATURE_____________________________

ITEM PART #

QUANTITY DESCRIPTION

1 2 3 4 5 6 7 8 NOTE: MELCO WILL CALL TO CONFIRM STOCK AVAILABILITY, PRICES & SHIPPING COSTS BEFORE CHARGING CREDIT CARD OR SHIPPING PARTS.

From the library of: Superior Sewing Machine & Supply LLC