ORDER FORM

 

Date _________________________                                           P.O. # ______________________________

to:

Q ENTERPRISES                                                            SHIP TO:

P.O. Box 234                                                                    Name: ___________________________________

Landing, NJ 07850                                                            Address: __________________________________

(973) 398-5901  FAX (973) 398-5681                            City: _____________________________________

                                                                                         State: _________________   Zip: _______________

Name____________________________________________________________________________

Address__________________________________________________________________________

City_____________________________________State___________________Zip_______________

Phone #________________________________________In case we need to contact you

   Quantity             Stock #                         Description                          Price                         Extension

_________        _________         _______________________    __________            _______________

_________        _________         _______________________    __________            _______________

_________        _________         _______________________    __________            _______________

_________        _________         _______________________    __________            _______________

_________        _________         _______________________    __________            _______________

_________        _________         _______________________    __________            _______________

_________        _________         _______________________    __________            _______________

_________        _________         _______________________    __________            _______________

Check Enclosed                                                                                                  Total_______________

Visa    Master Card    Discover                                          Special Handling Fee_______________

Card Number _ _ _ _   _ _ _ _   _ _ _ _   _ _ _ _                                       6% Sales Tax_______________

Expiration Date______________________                                             UPS/Insurance_______________

Signature___________________________                                             Total Enclosed_______________

Print Name__________________________