ORIGINAL COPY
BROCK TOOL COMPANY
NUMBER
DATE
R-
1401 E. RIVERSIDE DR. INDIANAPOLIS, IN 46202 Ph. 317.634.7575 Fx. 317.636.0588
DATE SHIPPED
SERVING INDUSTRY AND CONTRACT ORS
ACCT. NO.:
SHIP VIA
CUSTOMER ORDER NUMBER
TAKEN BY
QUAN.
BROCK NO.
SHIPPED
MANUFACTURER
DESCRIPTION
MODEL NO.
SERIAL NO.
PER
FILLED BY
DISC.
PARTS LABOR
TYPE GIVE ESTIMATE
VOLTAGE NAME
NO CLAIMS OR RETURNS ALLOWED AFTER 6 DAYS OF RECEIPT OF SHIPMENT WITHOUT AUTHORIZATION
NEW TOOL WARRANTY
BROCK WARRANTY
TELEPHONE NUMBER SPECIAL INSTRUCTIONS
FREIGHT CHARGES
CREDIT
ESTIMATE APPROVED BY
DATE
P/C