FAX ORDER FORM

Ordered By / Bill To:		Deliver To:
Name:		Name:
Company Name:		Company Name:
Account No.:		Account No.:
Suite Number:		Suite Number:
Street Address:		Street Address:
State:	Zip:	State:	Zip:
Phone Number:		Phone Number:
Fax Number:		Fax Number:
E-mail Address:

Special Instructions: _____________________________________________________________

Item Number	Description	Color	Unit	Price	Qty	Amount
Merchandise Total If Paying by Credit Card, Please fill out this section Applicable Sales Tax  VISA  MasterCard  American Express Total…………………….. Credit Card Number: __________________ Expiration Date ____ /______
Cardholder’s Name ____________________________________________ Cardholder’s Signature _________________________________________

Buyer’s Signature: _______________________________________ Date: ____________

Fax to Stephens Office Supply (757) 868-0507