Instructions: Print form and fax to MIS at 248-717-0898
Your Name: _________________________________ Phone: ____________________
Company: _____________________________________________________________
Address: _____________________________________________________________
City: _____________________________ST_________ZIP_____________________
E-Mail for Quotation ________________________________________________
Credit Card Number: _________________________ Exp
Date: _________ CVV: _____
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
_________ _________________________________________ ____
________
_________ _________________________________________ ____
________
_________ _________________________________________ ____
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_________ _________________________________________ ____
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6% MI Sales tax (Michigan deliveries
only)
________
Shipping (Will be added at the time of shipping)
________
Grand Total:.........................................
__________
Thank you for your order! Our Voice number is
800-445-8296 10am-5pm EST
If the Datacover you need is not listed use the form below to
specify