Specifications

ACCT #: P.O. #: DATE:
FAX ORDERING FORM
(SERVICE PARTS ONLY)
NAME: SHIP TO:
ADDRESS:
CITY, ST.:
CONTACT:
PHONE:
QTY. PART # DESCRIPTION (SPECIFY COLOR OF ITEM IF APPLICABLE) COLOR CODE PRICE/PER
METHOD OF SHIPMENT
NON-EMERGENCY ORDER - TO SHIP WITHIN 72 HOURS IF
PART(S) IN STOCK.
EMERGENCY ORDER - TO SHIP WITHIN 24 HOURS IF PART(S)
IN STOCK (IF ORDER IS RECEIVED BEFORE 1:00 P.M. E.S.T).
SEND NOTIFICATION IF PARTS ARE NOT AVAILABLE TO SHIP
WITHIN 24 HOURS VIA
E-MAIL OR FAX TO:
NOTES:
• ALL BLOCKED AREAS MUST BE COMPLETED.
• USE FOR NON-WARRANTY FAX ORDERS ONLY. WARRANTY ORDERS MUST BE TELEPHONED IN (1-800-MIDMARK).
ATTENTION: SERVICE DEPARTMENT FAX#: [phone]
NEXT DAY A.M.
NEXT DAY P.M.
2ND DAY
GROUND
NEXT DAY A.M.
NEXT DAY P.M.
2ND DAY
ECONOMY
UPS
FED EX
OTHER
TOTAL COST: $
© Midmark Corporation 2000 Rev. 1/07 Page 7-2 Printed in U.S.A.
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