P: 949.645.

1455
F: 949.645.1665
1537 Monrovia Ave
Newport Beach, CA 92663

CUSTOMER INFORMATION
Legal Business Name: _______________________________________________________________

Store Name: ________________________________________________________________________

Store Address: ______________________________________________________________________

City: __________________State: ___ Zip: _______ Phone: ______________ Fax: ______________

Buyer Contact(s): ___________________________________________________________________

Phone: _____________ Fax: _____________ Email Address: _______________________________

Phone: _____________ Fax: _____________ Email Address: _______________________________

ACCOUNTING INFORMATION
Billing Address: ______________________________________________________________________

City: __________________State: ___ Zip: _______ Phone: ______________ Fax: ______________

Accounts Payable Contact(s): _______________________________________________________

Phone: _____________ Fax: _____________ Email Address: _______________________________

Phone: _____________ Fax: _____________ Email Address: _______________________________

Desired Terms: ______________________________________________________________________

Include Invoice with Shipment? (YES/NO or Email upon shipping)

If emailing, please send to: __________________________________________________________

SHIPPING INFORMATION
Shipping Address: ___________________________________________________________________

City: __________________State: ___ Zip: _______ Phone: ______________ Fax: ______________

Shipping Contact(s): ________________________________________________________________

Phone: _____________ Fax: _____________ Email Address: _______________________________

Phone: _____________ Fax: _____________ Email Address: _______________________________

Desired Freight Method: __________________ Account # (if applicable): _________________

Special Instructions: _________________________________________________________________

 P: 949.645.1455
F: 949.645.1665
1537 Monrovia Ave
Newport Beach, CA 92663

Freight Forwarder (if applicable): ____________________________________________________

Freight Forwarder Contact(s): ________________________________________________________

Phone: _____________ Fax: _____________ Email Address: _______________________________

Phone: _____________ Fax: _____________ Email Address: _______________________________

Freight Forwarder Address: __________________________________________________________

City: __________________State: ___ Zip: _______ Phone: ______________ Fax: ______________

GENERAL ORDER INFO

• OK to Ship Backorders? (YES/NO or YES, but please contact me first)

• OK to Ship Early? (YES/NO or YES, but please contact me first)

• OK to Ship Past-Cancel? (YES/NO or YES, but please contact me first)

Special Comments: _________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________