Customer Information/Order Form

Please fill out this form to order any of our products or to request more information.

*Note: required entry field

You can also select to print this form and FAX it to us at: 1-541-342-1960


Full name *

Company name *
Job title Other:

Shipping address *
Street
City
State
Zip or Postal Code

Billing address * (if different from Shipping address) (NOTE: only for orders)
Street
City
State
Zip or Postal Code

Phone number *   -   Fax number -
E-mail

We welcome your feedback


To order our products, fill out the following:

[IMPORTANT NOTE: PO# IS REQUIRED IF YOU ARE ORDERING PRODUCTS]
Purchase Order Number (PO#)
1) Item Number Number of Units
2) Item Number Number of Units
3) Item Number Number of Units

Have you ordered from us before? Yes No



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