Company Name*
Email*
P.O. Number
JMS Account Number*
Contact
Phone Number*
Fax Number
Shipping Address*
Billing Address
Billing address is the same as shipping address
Shipping Information
Shipping Service UPS GroundUPS Next Day (by 8:30 AM)UPS Next Day (by 10:30 AM)UPS Next Day (by 3:00 PM)UPS 2nd Day (by 12:00 PM)UPS 2nd Day (Before 5:00 PM)UPS 3rd DayFed Ex GroundOther
Shipping Account Number
Back Orders Accepted? YesNo
Billing Information
Net 30 DaysCredit Card (Visa, Master Card, Amex) For "Net 30 Day" payments, please fill out a Credit Application
Name On Card
Card Number
Expiration Date
CVV
Quantity
Item number
Description
Unit Price
Amount
-+
Total
Fields marked with a * are required
