Master Distributors

• Credit Card Number: ____________________________________ Exp. Date: _______
• Name on Card: ________________________________________________________
• Address Card is Billed to: ________________________________________________________
• City: ___________________________________ State: _____ Zip: _______________
• Telephone: Daytime_____________________________
•                   Evening _____________________________
•                  FAX _______________________________
• Person Ordering: _____________________________________ Date __________
• Ship to : Name: ________________________________________________________
• Address: _____________________________________________________________
• City: ___________________________________ State: _____ Zip: _______________
• Telephone: __________________________  Estimate Ship Date _________________

QTY	-- ITEM NUMBER --	---------- DESCRIPTION ----------	--- EACH ---	---- TOTAL ----
.	.	.	.	.
.	.	.	.	.
.	.	.	.	.
.	.	.	.	.
.	.	.	.	.
			-- Sub-Total	.
		Michigan Residents Add 6 % Sales Tax	-- Sales Tax	.
		Shipping Weight -	-- Shipping	.
			-- TOTAL	.