POWELL'S EQUIPMENT SVC., INC.     

FAX ORDER FORM

PLEASE PRINT OUT FIRST AND THEN FILL OUT FIRMLY WITH PEN AND FAX TO 1-910-424-9563

NAME ________________________________________DATE______________________

ADDRESS ___________________________CITY/STATE ________________________ZIP____________

PHONE(___) ____-____ YEAR ______MAKE________ MODEL#_____________

GAS   OR  ELECTRIC___________                                SERIAL#__________________

QTY PART DESCRIPTION UNIT PRICE TOTAL
         
         
         
         
         
         
         
         

TOTAL OF PARTS=$____________

FREIGHT=$___________

NC TAX=$_________

SUBTOTAL=$________________

CIRCLE ONE:  VISA    DISCOVER    MC      AMEX      CC# _________________________________

SHIPMENT PREFER:   WILL SHIP REGULAR GROUND UNLESS NOTIFIED  ___________________