We accept purchase orders from government agency. Please print out this page and fill the form out as completely as possible then fax it back to us to process your order. Fax Number: (909) 590-5430 Shipping Info: Name of Contact:____________________________________ Name of Agency:____________________________________ Division/Department:_________________________________ Phone Number:(       )_____-______ Email Address:___________________ Shipping Address State Zip Code ________________________________             ____                 ________ Payment Info: Type of Credit Card: Credit Card Expiration Date: Month  /  Year Visa ____ ______ Master Card ____ ______ Discover ____ ______ Express ____ ______ Billing Address State Zip Code ________________________ ____ ________ Items You Want to Order: Product Name Code Price Qty. ______________________          ________       ___________    __________________ ______________________          ________       ___________    __________________ ______________________          ________       ___________    __________________ ______________________          ________       ___________    __________________ ______________________          ________       ___________    __________________ Special Instructions: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________