Purchase by Fax

TO: EZ Systems 3400 W MacArthur Blvd. #E Santa Ana, CA 92704 Tel:714-662-4959  Fax:714-662-6859  //www.ezsystems.com

My Email Address ?_______________________________ How did you find us ?__________________________

DATE:_______________________ Purchase Order Number:__________________ 

BILL TO:Company:_____________________________________CONTACT:__________________________________
Street Address: ____________________________________________________________________________________
City, State, Zip:_____________________________________________________________________________________

**BLIND SHIP**

Yes or No

SHIP TO:Company:_________________________________CONTACT:_________________________________
Street address:_________________________________________________________________________________
City, State, Zip: ________________________________________________________________________________
Buyer Contact:_____________________Phone#:________________ext.________Fax#:____________________
Technical Contact:________________Phone#:__________________ext._______Fax#:_____________________

MFG PN# / Model	Quantity	Description	Unit Price	Total	Warranty / Condition

Terms:_______ Credit Card#:___________________________________Exp:_________Holder Name:_____________________________

Shipping  _________________ 

My Carrier Account #:__________________Bill me Yes or No:______

COMMENTS:__________________________________________________________
____________________________________________________________________