Order Form

Customer Information Required fields are marked with *		Shipping Information If different from Customer Information
Company * Contact Person * Address * Address 2 City * State * Country * Zip Code * Phone Number * Fax Number Email Address *		Company Attn: Address Address 2 City State Country Zip Code Phone Number

Order Information
Purchase Order

Qty.	Stock Number	Item Description	Unit Price	Total Price

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Memo:

PRICE INFORMATION Pricing excludes 10% Federal Excise Tax and applicable sales taxes. DELIVERY Freight - FOB Lakeland Incorporated Isle, Minnesota

LAKELAND TERMS Open Account (Net 30 Days) for established credit accounts. Cash with Order or C.O.D. VISA/MASTERCARD