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Purchase Order No.:

LECORP Quote #:

Date Required:

 

  

Ship Via:

        UPS Ground   UPS NDA   UPS Blue   FedEx                        

          Averitt     ConWay     Yellow   Other
     
 

        PrePay and Add

     Collect Acct # 

Contact EMail:

Contact Name:
       
BILL TO:   SHIP TO:  
Company Name: Company Name:
Address: Address:
Address (cont): Address (cont):
City: City:
State:    Zip:  State: Zip: 
Phone Number: Fax Number:

 

QTY PART NUMBER UNIT PRICE EXTENDED PRICE

   

     Sub-Total  

 Sales Tax

Exempt

Tax Percent

Taxable State

    
If exempt, please fax a copy of exemption certificate to 270-554-9657. Total

IF CURRENT PRICING IS DIFFERENT THAN ABOVE, WE WILL NOTIFY YOU ACCORDINGLY

THANKS FOR YOUR ORDER.