Email Address:
Company Name:	Purchase Order No.:
Bill to Address:	Ship to Address:
Manufacturer's Model or Part No.:	Shipping Instructions/Markings:
Quantity:
Description:	Carrier Preferred:
Net Price Each:	Type of Shipment: UPS     Std.
Best Way Collect:
Total Net Price:	Best Way PPd & Add:
Taxable: Yes    No	Specify Other:
Tax ID No.:
HEI Quote No.:	Hold For Approval: Yes    No
Mfg's Bid No.:	Drawings Required: Yes    No
Send To (name):
Quoted By (Name):	Address:
Date of Quote:
Formal Quote: Yes   No
Verbal Quote: Yes   No
PREFERRED METHOD OF PAYMENT
COD   Net 30 Days
Phone # (for credit information):

PLEASE NOTE
1. Before providing card #, check with us to confirm the supplier accepts credit cards.
2. ALL URGENT Shipments require order to be called in or faxed direct to:
TEL:1-800-365-0041 OR 262-639-8763, FAX 262-639-2820
3. Each manufacture's warranty terms apply. Copy available on request.