Instructions: Print form and fax to MIS at 248-289-6013 

Your Name:_________________________________Phone:____________________

Company:_____________________________________________________________

Address:_____________________________________________________________

City:_____________________________ST_________ZIP_____________________

E-Mail for Quotation ________________________________________________

Credit Card Number:____________________________ Exp Date ____________

Credit Card Type:   MC     VISA    AMX    PO Number: ________________

Signature or Name on Card:___________________________________________

Shipping Method: FedEx Ground      FedEx 2nd Day     FedEx Next Day  
         
Part No.   Description                                QTY      Price
_________  _________________________________________  ____  ________

_________  _________________________________________  ____  ________

_________  _________________________________________  ____  ________

_________  _________________________________________  ____  ________

6% MI Sales tax (Michigan deliveries only)                  ________

Shipping and Handling  ($5.00 minimum, call for est)         ________

Grand Total:.........................................      __________

Thank you for your order! Our Voice number is 800-445-8296 8am-5pm EST

If the Datacover you need is not listed use the form below to specify

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