Instructions: Print form and fax to MIS at
248-717-0898

Your Name: _________________________________ Phone: ____________________

Company: _____________________________________________________________

Address: _____________________________________________________________

City: _____________________________ST_________ZIP_____________________

E-Mail for Quotation ________________________________________________

Credit Card Number: _________________________ Exp Date: _________ CVV: _____

Credit Card Type:   MC     VISA    AMX    PO Number: ________________

Signature or Name on Card:___________________________________________

Shipping Method: FedEx Ground      FedEx 2nd Day     FedEx Next Day 
        
Part No.   Description                                QTY      Price
_________  _________________________________________  ____  ________

_________  _________________________________________  ____  ________

_________  _________________________________________  ____  ________

_________  _________________________________________  ____  ________

6% MI Sales tax (Michigan deliveries only)                  ________

Shipping (Will be added at the time of shipping)            ________

Grand Total:.........................................      __________

Thank you for your order! Our Voice number is 800-445-8296 10am-5pm EST

If the Datacover you need is not listed use the form below to specify